Gender differences in pre-hospital time delay and symptom presentation in patients suspected of acute coronary syndrome in primary care

OBJECTIVE

To describe gender differences in pre-hospital delay times and symptom presentation in patients suspected of acute coronary syndrome (ACS) in a primary care setting.

METHODS

Over 150 participating GPs included 298 consecutive patients suspected of ACS (52% female, mean age 66 years, 22% eventually diagnosed with ACS according to international guidelines) in a 28-month time period. Data on time from call for help until GP consultation (doctor delay) were prospectively collected, while the time from onset of symptoms until call for help (patient delay) was recorded by the GP at the time of arrival at the patient, together with patient characteristics, including age, sex, previous medical history, chest pain, radiation of chest pain and nausea/sweating.

RESULTS

Median doctor delay was 45 [interquartile range (IQR) 20-55] minutes in women and 33 (IQR 26-72) minutes in men (P = 0.01). Median patient delay was 108 (IQR 39-348) minutes in women and 180 (IQR 48-396) minutes in men (P = 0.20). Women reported spreading chest pain more often than men (68% versus 57%, P = 0.06). Women diagnosed with ACS were older than men (mean 75 years versus 65 years, P < 0.001).

CONCLUSIONS

In patients suspected of ACS in primary care, no differences were found in patient delay, but doctor delay was longer in women than in men. Symptom presentation was largely similar between men and women, although women tended to report 'spreading' chest pain more often.

Heart-type Fatty acid-binding protein in Acute Myocardial infarction Evaluation (FAME): background and design of a diagnostic study in primary care

BACKGROUND

Currently used biomarkers for cardiac ischemia are elevated in blood plasma after a delay of several hours and therefore unable to detect acute coronary syndrome (ACS) in a very early stage. General practitioners (GPs), however, are often confronted with patients suspected of ACS within hours after onset of complaints. This ongoing study aims to evaluate the added diagnostic value beyond clinical assessment for a rapid bedside test for heart-type fatty-acid binding protein (H-FABP), a biomarker that is detectable as soon as one hour after onset of ischemia.

METHODS

Participating GPs perform a blinded H-FABP rapid bedside test (Cardiodetect) in patients with symptoms suggestive of ACS such as chest pain or discomfort at rest. All patients, whether referred to hospital or not, undergo electrocardiography (ECG) and venapunction for a plasma troponin test within 12-36 hours after onset of complaints. A final diagnosis will be established by an expert panel consisting of two cardiologists and one general practitioner (blinded to the H-FABP test result), using all available patient information, also including signs and symptoms. The added diagnostic value of the H-FABP test beyond history taking and physical examination will be determined with receiver operating characteristic curves derived from multivariate regression analysis.

CONCLUSION

Reasons for presenting the design of our study include the prevention of publication bias and unacknowledged alterations in the study aim, design or data-analysis. To our knowledge this study is the first to assess the diagnostic value of H-FABP outside a hospital-setting. Several previous hospital-based studies showed the potential value of H-FABP in diagnosing ACS. Up to now however it is unclear whether these results are equally promising when the test is used in primary care. The first results are expected in the end of 2008.

Magnesium therapy in acute myocardial infarction

The trials reviewed in this study investigated the effect of intravenous magnesium on arrhythmias and mortality in acute myocardial infarction. Nine trials were carried out in the pre-thrombolytic era. They varied in set-up, number of patients, dose of magnesium, follow-up and the type of arrhythmias analyzed. Magnesium reduced mortality in most studies, but the reduction was significant in only three of them. Two meta-analyses of the smaller studies revealed a 55% reduction in mortality. In the LIMIT-2, in which 2300 patients were enrolled, magnesium reduced mortality significantly by 24%. The effect of magnesium on arrhythmias was less clear. Preliminary results of ISIS-4, in which magnesium among others was administered together with thrombolytic agents, did not provide evidence of benefit in patients with suspected myocardial infarction. At present there are no arguments for the use of magnesium in acute myocardial infarction.

A double-blind randomized multicenter dose-ranging trial of intravenous streptokinase in acute myocardial infarction

Intravenous streptokinase administration is now a widely applied therapy for patients in the early hours of acute myocardial infarction (AMI). The dosages used do not appear to be based on comparative clinical investigations. Therefore a double-blind randomized trial was carried out to establish the optimal dose of streptokinase. A total of 189 patients who had symptoms of AMI for less than 4 hours were treated with 200,000, 750,000, 1,500,000 or 3,000,000 IU streptokinase intravenously. At coronary angiography 2.8 +/- 2.7 hours (mean +/- standard deviation) after the start of streptokinase infusion, patency of the infarct-related coronary artery was observed in 38, 75, 60 and 82% of the patients, respectively, in the 4 groups. The result of the dosage of 200,000 IU was significantly poorer than that of the other dosages (p less than 0.01). The result of a dosage of 3,000,000 IU was significantly better than that of 1,500,000 IU (p less than 0.05), but the differences with 750,000 IU were not significant. Blood transfusion was required in 4 patients (2%), distributed over the 4 groups in 0, 2, 1 and 1 of the patients. One patient had major bleeding; this patient had been treated with 750,000 IU. The 3-month mortality-rate in the whole study population was 5%. Thus, of the 4 doses of streptokinase tested, 750,000 IU is the minimal therapeutic dosage, and the arguments for 1,500,000 IU as standard therapy for comparison with other fibrinolytic drugs are poor. The best results in this study were achieved with 3,000,000 IU, but further research will be needed to establish the efficacy and safety of this new regimen.