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Settelmeier S, Steven S, Post F, Ahrens I, Giannitsis E, Breuckmann F. New categorization of chest pain: noncardiac is in, atypical is out! Herz 2024; 49:181-184. [PMID: 38427126 DOI: 10.1007/s00059-024-05240-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2024] [Indexed: 03/02/2024]
Abstract
Chest pain poses a diagnostic challenge in the emergency department and requires a thorough clinical assessment. The traditional distinction between "atypical" and "typical" chest pain carries the risk of not addressing nonischemic clinical pictures. The newly conceived subdivision into cardiac, possibly cardiac, and (probably) noncardiac causes of the presenting symptom complex addresses a much more interdisciplinary approach to a symptom-oriented diagnostic algorithm. The diagnostic structures of the chest pain units in Germany do not currently reflect this. An adaptation should therefore be considered.
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Affiliation(s)
- Stephan Settelmeier
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Sebastian Steven
- Med. Klinik III-Department for Cardiology, University Hospital Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Germany
| | - Felix Post
- Internal Medicine, General and interventional Cardiology, Katholisches Klinikum Koblenz-Montabaur, Rudolf-Virchow-Str. 7-9, 56073, Koblenz, Germany
| | - Ingo Ahrens
- Krankenhaus der Augustinerinnen, Department for Cardiology and Intensive Care Medicine, Jakobstr. 27-31, 50678, Köln, Germany
| | - Evangelos Giannitsis
- Department for Internal Medicine III, Cardiology, Vascular Medicine and Pneumology, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120, Heidelberg, Germany
| | - Frank Breuckmann
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, Hufelandstr. 55, 45147, Essen, Germany.
- Cardiology, Pneumology, Neurology and Intensive Care Medicine, Klinik Kitzinger Land, Keltenstr. 67, 97318, Kitzingen, Germany.
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Imhof S, Hochadel M, Konstantinides S, Voigtländer T, Schmitt C, Nowak B, Rassaf T, Senges J, Münzel T, Giannitsis E, Breuckmann F. Cardiac, possible cardiac, and likely non-cardiac origin of chest pain : A hitherto underestimated parameter in German chest pain units. Herz 2024; 49:175-180. [PMID: 38155226 DOI: 10.1007/s00059-023-05230-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND Current guidelines emphasize the diagnostic value of non-cardiac or possibly cardiac chest pain. The goal of this analysis was to determine whether German chest pain units (CPUs) adequately address conditions with "atypical" chest pain in existing diagnostic structures. METHOD A total of 11,734 patients from the German CPU registry were included. The analyses included mode of admission, critical time intervals, diagnostic steps, and differential diagnoses. RESULTS Patients with unspecified chest pain were younger, more often female, were less likely to have classic cardiovascular risk factors and tended to present more often as self-referrals. Patients with acute coronary syndrome (ACS) mostly had prehospital medical contact. Overall, there was no difference between these two groups regarding the time from the onset of first symptoms to arrival at the CPU. In the CPU, the usual basic diagnostic measures were performed irrespective of ACS as the primary working diagnosis. In the non-ACS group, further ischemia-specific diagnostics were rarely performed. Extra-cardiac differential diagnoses were not specified. CONCLUSION The establishment of broader awareness programs and opening CPUs for low-threshold evaluation of self-referring patients should be discussed. Regarding the rigid focus on the clarification of cardiac causes of chest pain, a stronger interdisciplinary approach should be promoted.
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Affiliation(s)
- Sebastian Imhof
- Department of Cardiology, Pneumology, Neurology and Intensive Care, Klinik Kitzinger Land, Kitzingen, Germany
| | - Matthias Hochadel
- Institute for Myocardial Infarction Research Foundation, Ludwigshafen, Germany
| | - Stavros Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | | | - Claus Schmitt
- Clinic for Cardiology and Angiology, Municipal Hospital Karlsruhe, Karlsruhe, Germany
| | - Bernd Nowak
- CCB, Cardioangiologisches Centrum Bethanien, Frankfurt am Main, Germany
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Duisburg-Essen, Essen, Germany
| | - Jochen Senges
- Institute for Myocardial Infarction Research Foundation, Ludwigshafen, Germany
| | - Thomas Münzel
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University Mainz, Mainz, Germany
| | | | - Frank Breuckmann
- Department of Cardiology, Pneumology, Neurology and Intensive Care, Klinik Kitzinger Land, Kitzingen, Germany.
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Duisburg-Essen, Essen, Germany.
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Clinical characteristics and in-hospital management strategies in patients with acute coronary syndrome: results from 2,096 accredited Chest Pain Centers in China from 2016 to 2021. CARDIOLOGY PLUS 2022. [DOI: 10.1097/cp9.0000000000000032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
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Dawson LP, Smith K, Cullen L, Nehme Z, Lefkovits J, Taylor AJ, Stub D. Care Models for Acute Chest Pain That Improve Outcomes and Efficiency. J Am Coll Cardiol 2022; 79:2333-2348. [DOI: 10.1016/j.jacc.2022.03.380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/30/2022] [Accepted: 03/30/2022] [Indexed: 10/18/2022]
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Gaber MA, Omar OHM, El-Deek SEM, Hassan AKM, Mahmoud MS, Meki ARMA. Copeptin, miRNA-208, and miRNA-499 as New Biomarkers for Early Detection of Acute Coronary Syndrome. Appl Biochem Biotechnol 2022; 194:1193-1205. [PMID: 34637111 DOI: 10.1007/s12010-021-03695-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 10/04/2021] [Indexed: 01/03/2023]
Abstract
cTn and CK-MB are gold standard biomarkers for acute coronary syndrome (ACS) but are less sensitive in the first 3 h after onset of symptoms. A need thus exists for novel biomarkers for early detection of ACS. We evaluated circulating copeptin, miRNA-208, and miRNA-499 as possible biomarkers for early detection of unstable angina (UA) and non-ST-segment elevation myocardial infarction (NSTEMI). Sixty-five patients with probable ACS that presented within 4 h of the onset of chest pain (23 UA and 42 NSTEMI) and 25 apparently healthy individuals were studied. Two sets of blood samples collected in the first 3 h and at 6 h after onset were analyzed for copeptin levels via ELISA and miRNA-208 and miRNA-499 expression via real-time PCR. Copeptin, miRNA-208, and miRNA-499 expression levels were significantly increased in UA and NSTEMI patients compared with controls (p < 0.001) and in NSTEMT compared with UA patients (p < 0.001). Levels were also significantly elevated in UA and NSTEMI patients with negative cardiac troponin in the first 3 h (p < 0.001). ROC curves displayed AUC for prediction of ACS of 0.96 for copeptin, 0.97 for miRNA-208, and 0.97 for miRNA-499. Their combination improved AUC to 0.98. Copeptin and miRNA-208 and miRNA-499 expression are promising biomarkers for UA and NSTEMI that present in the first 3 h of pain onset. A combination of these markers with cTn may increase the accuracy of diagnosis by avoiding the gray zone of cTn as a biomarker.
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Affiliation(s)
- Marwa A Gaber
- Medical Biochemistry Department, Faculty of Medicine, Assiut University, Assiut, Egypt.
| | - Omnia H M Omar
- Assiut International Center of Nanomedicine, El-rajhy liver Hospital, Assiut University, Assiut, Egypt
| | - Sahar E M El-Deek
- Medical Biochemistry Department, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ayman K M Hassan
- Cardiology Department, Faculty of Medicine,, Assiut University, Assiut, Egypt
| | - Marwan S Mahmoud
- Cardiology Department, Faculty of Medicine,, Assiut University, Assiut, Egypt
| | - Abdel-Raheim M A Meki
- Medical Biochemistry Department, Faculty of Medicine, Assiut University, Assiut, Egypt
- iochemistry Department, Faculty of Pharmacy, Sphinx University, New Assiut, Egypt Corresponding author: Assistant Professor Marwa A Gaber, Medical Biochemistry Department, Faculty of Medicine, Assiut University, Assiut, Egypt
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Raven W, van den Hoven EMP, Gaakeer MI, Ter Avest E, Sir O, Lameijer H, Hessels RAPA, Reijnen R, van Zwet E, de Jonge E, Nickel CH, de Groot B. The association between presenting complaints and clinical outcomes in emergency department patients of different age categories. Eur J Emerg Med 2022; 29:33-41. [PMID: 34406137 DOI: 10.1097/mej.0000000000000860] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND IMPORTANCE Although aging societies in Western Europe use presenting complaints (PCs) in emergency departments (EDs) triage systems to determine the urgency and severity of the care demand, it is unclear whether their prognostic value is age-dependent. OBJECTIVE To assess the frequency and association of PCs with hospitalization and mortality across age categories. METHODS An observational multicenter study using all consecutive visits of three EDs in the Netherlands Emergency department Evaluation Database. Patients were stratified by age category (0-18; 19-50; 51-65; 66-80; >80 years), in which the association between PCs and case-mix adjusted hospitalization and mortality was studied using multivariable logistic regression analysis (adjusting for demographics, hospital, disease severity, comorbidity and other PCs). RESULTS We included 172 104 ED-visits. The most frequent PCs were 'extremity problems' [range across age categories (13.5-40.8%)], 'feeling unwell' (9.5-23.4%), 'abdominal pain' (6.0-13.9%), 'dyspnea' (4.5-13.3%) and 'chest pain' (0.6-10.7%). For most PCs, the observed and the case-mix-adjusted odds for hospitalization and mortality increased the higher the age category. The most common PCs with the highest adjusted odds ratios (AORs, 95% CI) for hospitalization were 'diarrhea and vomiting' [2.30 (2.02-2.62)] and 'feeling unwell' [1.60 (1.48-1.73)]. Low hospitalization risk was found for 'chest pain' [0.58 (0.53-0.63)] and 'palpitations' [0.64 (0.58-0.71)]. CONCLUSIONS Frequency of PCs in ED patients varies with age, but the same PCs occur in all age categories. For most PCs, (case-mix adjusted) hospitalization and mortality vary across age categories. 'Chest pain' and 'palpitations,' usually triaged 'very urgent', carry a low risk for hospitalization and mortality.
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Affiliation(s)
- Wouter Raven
- Department of Emergency Medicine, Leiden University Medical Centre, Leiden
| | | | | | - Ewoud Ter Avest
- Department of Emergency Medicine, University Medical Centre Groningen, Groningen
| | - Ozcan Sir
- Department of Emergency Medicine, Radboud University Medical Centre, Nijmegen
| | - Heleen Lameijer
- Department of Emergency Medicine, Medical Centre Leeuwarden, Leeuwarden
| | | | - Resi Reijnen
- Department of Emergency Medicine, Haaglanden Medical Centre, The Hague
| | - Erik van Zwet
- Department of Biostatistics, Leiden University Medical Centre, Leiden
| | - Evert de Jonge
- Department of Intensive Care, Leiden University Medical Centre, Leiden, the Netherlands
| | | | - Bas de Groot
- Department of Emergency Medicine, Leiden University Medical Centre, Leiden
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Breuckmann F, Nabavi DG, Post F, Grau AJ, Giannitsis E, Hochadel M, Senges J, Busse O, Münzel T. [Comparison between chest pain units and stroke units : Essential components of the vascular emergency care system: comparison of structure, certification process, quality benchmarking and reimbursement]. Herz 2021; 46:141-150. [PMID: 32990815 PMCID: PMC7523490 DOI: 10.1007/s00059-020-04984-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 08/17/2020] [Accepted: 08/26/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Chest pain units (CPU) and stroke units (SU) have both become established as essential components of clinical emergency care. For both instances dedicated certification processes are installed. Up to summer 2020, 290 CPUs and 335 SUs have been successfully certified. OBJECTIVE The aim of this review is to compare the structures and the current certification situation of CPUs and SUs. Also, the younger CPU certification process is compared to the long established SU certification standard. MATERIAL UND METHODS The comparison includes the historical background, the certification process, quality benchmarking, possible additive structures, the current status of certification in Germany, the transfer of the concept to the European level as well as reimbursement issues. RESULTS Both certification concepts show clear analogies. Evidence for SUs is supported by a positive Cochrane analysis and for CPUs there are many studies from the German CPU registry. The main differences include a uniform CPU system versus a multistep SU system of certification. Furthermore, SU have obligatory elements of quality documentation but only facultative quality indicator assessment for CPUs. From an economic viewpoint operation and procedural key (OPS) numbers guarantee a better reflection of the use of resources in the complex treatment of stroke, which could not yet be established for CPUs. CONCLUSION The well-established CPU concept could additionally benefit from a superordinate quality control. Adequate quality benchmarking appears to be fundamental for gap analyses and for the establishment of a separate remuneration structure. In this respect the German Society for Cardiology as the certifying institution is required to establish an appropriate mechanism within the framework of regular updates of criteria.
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Affiliation(s)
- Frank Breuckmann
- Medizinische Klinik I, Herz-Jesu-Krankenhaus Dernbach, Südring 8, 56428, Dernbach, Deutschland.
| | - Darius G Nabavi
- Neurologie mit Stroke Unit, Vivantes Klinikum Neukölln, Berlin, Deutschland
| | - Felix Post
- Klinik für Kardiologie, Katholisches Klinikum Koblenz-Montabaur, Koblenz, Deutschland
| | - Armin J Grau
- Klinik für Neurologie, Klinikum Ludwigshafen, Ludwigshafen am Rhein, Deutschland
| | - Evangelos Giannitsis
- Zentrum für Kardiologie, Angiologie, Pneumologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Matthias Hochadel
- Stiftung Institut für Herzinfarktforschung, Ludwigshafen, Deutschland
| | - Jochen Senges
- Stiftung Institut für Herzinfarktforschung, Ludwigshafen, Deutschland
| | - Otto Busse
- Deutsche Schlaganfall-Gesellschaft, Berlin, Deutschland
| | - Thomas Münzel
- Zentrum für Kardiologie, Kardiologie I, Universitätsmedizin Mainz, Mainz, Deutschland
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Li T, Wu J, Liu J, Sun W, Qi C, Liu B, Wells GA, Wang J. Protocol for the Acute Myocardial Infarction Study in Northeastern China (AMINoC): a real-world prospective cohort study. BMJ Open 2021; 11:e042936. [PMID: 34035090 PMCID: PMC8154984 DOI: 10.1136/bmjopen-2020-042936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 03/11/2021] [Accepted: 04/14/2021] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Acute myocardial infarction (AMI) has become one of the major causes of mortality and morbidity in China. However, little is known about the characteristics, medical care and outcomes of patients with AMI in Northeastern China. The Acute Myocardial Infarction Study in Northeastern China (AMINoC) is aimed at obtaining timely real-world knowledge in terms of characteristics, clinical care and outcomes of patients with AMI and at providing care-quality improvement efforts in Northeastern China. METHODS AND ANALYSIS The AMINoC is a real-world, prospective, multicentre cohort study. The study selected 20 hospitals using stratified cluster sampling from different levels of hospitals among nine districts throughout Jilin Province. Hospitalised patients with a primary diagnosis of AMI in each site are consecutively enrolled for 1 year. Demographic characteristics, clinical data, treatments, outcomes and cost are collected by local investigators. Patient follow-up after discharge is planned for up to 2 years. ETHICS AND DISSEMINATION The protocol has been approved by the ethics committee at the Second Hospital of Jilin University. The findings of this study will be published in peer-reviewed journals and medical conferences. TRIAL REGISTRATION NCT04451967.
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Affiliation(s)
- Tianyi Li
- Department of Cardiology, the Second Hospital of Jilin University, Changchun, Jilin, China
| | - Junduo Wu
- Department of Cardiology, the Second Hospital of Jilin University, Changchun, Jilin, China
| | - Jia Liu
- Department of Cardiology, the Second Hospital of Jilin University, Changchun, Jilin, China
| | - Wei Sun
- Department of Cardiology, the Second Hospital of Jilin University, Changchun, Jilin, China
| | - Chao Qi
- Department of Cardiology, the Second Hospital of Jilin University, Changchun, Jilin, China
| | - Bin Liu
- Department of Cardiology, the Second Hospital of Jilin University, Changchun, Jilin, China
| | - George A Wells
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
- Cardiovascular Research Methods Centre, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Junnan Wang
- Department of Cardiology, the Second Hospital of Jilin University, Changchun, Jilin, China
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Sun P, Li J, Fang W, Su X, Yu B, Wang Y, Li C, Chen H, Wang X, Zhang B, Li Y, Momin M, Shi Y, Wang H, Zhang Y, Xiang D, Huo Y. Effectiveness of chest pain centre accreditation on the management of acute coronary syndrome: a retrospective study using a national database. BMJ Qual Saf 2020; 30:867-875. [PMID: 33443197 DOI: 10.1136/bmjqs-2020-011491] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 11/22/2020] [Accepted: 11/26/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Large-scale real-world data to evaluate the impact of chest pain centre (CPC) accreditation on acute coronary syndrome (ACS) emergency care in heavy-burden developing countries like China are rare. METHODS This study is a retrospective study based on data from the Hospital Quality Monitoring System (HQMS) database. This study included emergency patients admitted with ACS to hospitals that uploaded clinical data continuously to the database from 2013 to 2016. Propensity score matching was used to compare hospitals with and without CPC accreditation during this period. A longitudinal self-contrast comparison design with mixed-effects models was used to compare management of ACS before and after accreditation. RESULTS A total of 798 008 patients with ACS from 746 hospitals were included in the analysis. After matching admission date, hospital levels and types and adjusting for possible covariates, patients with ACS admitted to accredited CPCs had lower in-hospital mortality (OR=0.70, 95% CI 0.53 to 0.93), shorter length of stay (LOS; adjusted multiplicative effect=0.89, 95% CI 0.84 to 0.94) and more percutaneous coronary intervention (PCI) procedures (OR=3.53, 95% CI 2.20 to 5.66) than patients admitted in hospitals without applying for CPC accreditation. Furthermore, when compared with the 'before accreditation' group only in accredited CPCs, the in-hospital mortality and LOS decreased and the usage of PCI were increased in both 'accreditation' (for in-hospital mortality: OR=0.86, 95% CI 0.79 to 0.93; for LOS: 0.94, 95% CI 0.93 to 0.95; for PCI: OR=1.22, 95% CI 1.18 to 1.26) and 'after accreditation' groups (for in-hospital mortality: OR=0.90, 95% CI 0.84 to 0.97; for LOS: 0.89, 95% CI 0.89 to 0.90; for PCI: OR=1.36, 95% CI 1.33 to 1.39). The significant benefits of decreased in-hospital mortality, reduced LOS and increased PCI usage were also observed for patients with acute myocardial infarction. CONCLUSIONS CPC accreditation is associated with better management and in-hospital clinical outcomes of patients with ACS. CPC establishment and accreditation should be promoted and implemented in countries with high levels of ACS.
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Affiliation(s)
- Pengfei Sun
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Jianping Li
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Weiyi Fang
- Department of Cardiology, Shanghai Chest Hospital, Shanghai, China
| | - Xi Su
- Department of Cardiology, Wuhan Asia Heart Hospital, Wuhan, China
| | - Bo Yu
- Department of Cardiology, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China.,The Key Laboratory of Myocardial Ischemia, Harbin Medical University, Ministry of Education, Harbin, China
| | - Yan Wang
- Department of Cardiology, Xiamen Cardiovascular Hospital Xiamen university, Xiamen, Fujian, China
| | - Chunjie Li
- Emergency Department, Tianjin Chest Hospital, Tianjin, China
| | - Hu Chen
- Corporate Ethics Department, Bureau of Medical Administration National Health Commission of the People's Republic of China, Beijing, China
| | - Xingang Wang
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Bin Zhang
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Yuxi Li
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Mohetaboer Momin
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Ying Shi
- China Standard Medical Information Research Center, Shenzhen, Guangdong, China
| | - Haibo Wang
- Clinical Trial Unit, First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Yan Zhang
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Dingcheng Xiang
- Department of Cardiology, General Hospital of Southern Theatre Command of PLA, Guangzhou, Guangdong, China
| | - Yong Huo
- Department of Cardiology, Peking University First Hospital, Beijing, China
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Lang CN, Kaier K, Zotzmann V, Stachon P, Pottgiesser T, von Zur Muehlen C, Zehender M, Duerschmied D, Schmid B, Bode C, Wengenmayer T, Staudacher DL. Cardiogenic shock: incidence, survival and mechanical circulatory support usage 2007-2017-insights from a national registry. Clin Res Cardiol 2020; 110:1421-1430. [PMID: 33258007 PMCID: PMC8405485 DOI: 10.1007/s00392-020-01781-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 11/11/2020] [Indexed: 12/12/2022]
Abstract
Background A central element in the management of cardiogenic shock (CS) comprises mechanical circulatory support (MCS) systems to maintain cardiac output (CO). This study aims to quantify incidence, outcome and influence of MCS in CS over the last decade. Methods All patients hospitalized with CS in a tertiary university hospital in Germany between 2007 and 2017 were identified utilizing the international coding system ICD-10 with code R57.0. Application of MCS was identified via German procedure classification codes (OPS). Results 383,983 cases of cardiogenic shock were reported from 2007 to 2017. Patients had a mean age of 71 years and 38.5% were female. The incidence of CS rose by 65.6% from 26,828 cases in 2007 (33.1 per 100,000 person-years, hospital survival 39.2%) to 44,425 cases in 2017 (53.7 per 100,000 person-years, survival 41.2%). In 2007, 16.0% of patients with CS received MCS (4.6 per 100,000 person-years, survival 46.6%), dropping to 13.9% in 2017 (6.6 per 100,000 person-years, survival 38.6%). Type of MCS changed over the years, with decreasing use of the intra-aortic balloon pump (IABP), an increase in extracorporeal membrane oxygenation (VA-ECMO) and percutaneous ventricular assist device (pVAD) usage. Significant differences regarding in-hospital survival were observed between the devices (survival: overall: 40.2%; medical treatment = 39.5%; IABP = 49.5%; pVAD = 36.2%; VA-ECMO = 30.5%; p < 0.001). Conclusions The incidence of CS is increasing, but hospital survival remains low. MCS was used in a minority of patients, and the percentage of MCS usage in CS has decreased. The use rates of the competing devices change over time. Graphical Abstract ![]()
Electronic supplementary material The online version of this article (10.1007/s00392-020-01781-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Corinna N Lang
- Heart Center Freiburg University, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany.
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Klaus Kaier
- Faculty of Medicine, Institute for Medical Biometry and Statistics, University of Freiburg, Freiburg, Germany
| | - Viviane Zotzmann
- Heart Center Freiburg University, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Peter Stachon
- Heart Center Freiburg University, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Torben Pottgiesser
- Heart Center Freiburg University, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Constantin von Zur Muehlen
- Heart Center Freiburg University, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Manfred Zehender
- Heart Center Freiburg University, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Daniel Duerschmied
- Heart Center Freiburg University, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Bonaventura Schmid
- Department of Emergency Medicine, University Hospital of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Bode
- Heart Center Freiburg University, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tobias Wengenmayer
- Heart Center Freiburg University, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Dawid L Staudacher
- Heart Center Freiburg University, Department of Cardiology and Angiology I, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Geyer M, Wild J, Münzel T, Gori T, Wenzel P. State of the Art-High-Sensitivity Troponins in Acute Coronary Syndromes. Cardiol Clin 2020; 38:471-479. [PMID: 33036710 DOI: 10.1016/j.ccl.2020.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
In cases of suspected acute coronary syndrome (ACS), rapid and accurate diagnosis is essential to establish effective evidence-based medical treatment. Patients' history, clinical examination, 12-lead electrocardiogram, and cardiac biomarkers are cornerstones in initial management. Since high-sensitivity cardiac troponins were established, they have markedly expedited and revolutionized rule-in and rule-out pathways of patients with ACS and changed our everyday clinical practice. Thus, they have become an indispensable tool in daily routine in emergency units. This review focuses on historical and contemporary standards in laboratory biomarkers of myocardial injury and discusses their implication in the context of the updated universal definition of myocardial infarction.
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Affiliation(s)
- Martin Geyer
- Department of Cardiology, Cardiology I, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany.
| | - Johannes Wild
- Department of Cardiology, Cardiology I, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany; Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany
| | - Thomas Münzel
- Department of Cardiology, Cardiology I, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany
| | - Tommaso Gori
- Department of Cardiology, Cardiology I, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany
| | - Philip Wenzel
- Department of Cardiology, Cardiology I, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany; Center for Thrombosis and Hemostasis, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, University Medical Center of the Johannes Gutenberg University Mainz, Langenbeckstr. 1, 55131 Mainz, Germany
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12
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A proposal for implementation of the chest pain unit model in Greece. Hellenic J Cardiol 2020; 62:304-305. [PMID: 32781304 DOI: 10.1016/j.hjc.2020.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 06/28/2020] [Accepted: 07/13/2020] [Indexed: 11/22/2022] Open
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German chest pain unit registry: data review after the first decade of certification. Herz 2020; 46:24-32. [PMID: 32232516 DOI: 10.1007/s00059-020-04912-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 01/24/2020] [Accepted: 03/03/2020] [Indexed: 01/12/2023]
Abstract
In 2008, the German Cardiac Society (GCS) introduced a certification program for specialized chest pain units (CPUs). In order to benchmark the performance of the certified CPUs, a nationwide German CPU registry was established. Since then, data for more than 34,000 patients have been included. The concept of certified CPUs in Germany has been widely accepted and its success is underlined by its recent inclusion in national and international guidelines. As of December 2019, 286 CPUs have been successfully certified or recertified by the GCS. This review focuses on the data retrieved from the CPU registry during the first decade of certification. As demonstrated by 16 manuscripts stemming from the registry, certified German CPUs demonstrate high quality of care in acute coronary syndrome and beyond. It is also noted that the German CPU registry allowed for further analysis of the gap in guideline adherence. With the current update of the CPU certification criteria, central data collection as a best-practice criterion will be abandoned, and after some productive years the registry has temporarily been stopped.
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14
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Amann M, Gaiser F, Schwenk SI, Rahimi F, Schmitz R, Mashayekhi K, Ferenc M, Neumann FJ, Valina CM, Hochholzer W. Evaluation of a 1-hour troponin algorithm for diagnosing myocardial infarction in high-risk patients admitted to a chest pain unit: the prospective FAST-MI cohort study. BMJ Open 2019; 9:e032124. [PMID: 31699742 PMCID: PMC6858235 DOI: 10.1136/bmjopen-2019-032124] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 10/07/2019] [Accepted: 10/09/2019] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE This study sought to evaluate the diagnostic performance of the 1-hour troponin algorithm for diagnosis of myocardial infarction (MI) without persistent ST-segment elevations (non-ST-segment MI (NSTEMI)) in a cohort with a high prevalence of MI. This algorithm recommend by current guidelines was previously developed in cohorts with a prevalence of MI of less than 20%. DESIGN Prospective cohort study from November 2015 until December 2016. SETTING Dedicated chest pain unit of a single referral centre. PARTICIPANTS Consecutive patients with suspected MI were screened. Patients with subacute symptoms lasting more than 24 hours, new ST-segment elevations at presentation, or an already diagnosed or ruled-out acute MI were excluded. All enrolled patients (n=1317) underwent a full clinical assessment and measurements of high-sensitivity troponin, and were scheduled for an early invasive strategy if clinically indicated. MAIN OUTCOME MEASURES Final diagnosis of MI according to the Fourth Universal Definition of MI. RESULTS The prevalence of NSTEMI in the present cohort was 36.9%. The sensitivity for rule-out of MI was 99.8%. The specificity for rule-in of MI was found to be 94.3%. However, in 35.7% of patients neither rule-in nor rule-out was possible. In 51.4% of patients diagnosed with MI, a primary non-coronary reason for MI was found (type 2 MI). Different receiver operating characteristic-curve derived cut-offs for troponin and its dynamics did not provide a sufficient differentiation between type 1 and 2 MI for clinical decision making (negative predictive value for rule-out of type 1 MI <70%). CONCLUSIONS The 1-hour diagnosis algorithm for patients with suspected NSTEMI can accurately diagnose acute MI in high-risk cohorts. However, discrimination between patients needing an early invasive strategy or not is limited. TRIAL REGISTRATION NUMBER DRKS00009713.
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Affiliation(s)
- Michael Amann
- Department of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Felix Gaiser
- Department of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Sandra Iris Schwenk
- Department of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Faridun Rahimi
- Department of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Roland Schmitz
- Department of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Kambis Mashayekhi
- Department of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Miroslaw Ferenc
- Department of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Franz-Josef Neumann
- Department of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Christian Marc Valina
- Department of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
| | - Willibald Hochholzer
- Department of Cardiology and Angiology II, University Heart Center Freiburg-Bad Krozingen, Bad Krozingen, Germany
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15
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Fan F, Li Y, Zhang Y, Li J, Liu J, Hao Y, Smith SC, Fonarow GC, Taubert KA, Ge J, Zhao D, Huo Y. Chest Pain Center Accreditation Is Associated With Improved In-Hospital Outcomes of Acute Myocardial Infarction Patients in China: Findings From the CCC-ACS Project. J Am Heart Assoc 2019; 8:e013384. [PMID: 31630594 PMCID: PMC6898834 DOI: 10.1161/jaha.119.013384] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Background Chest pain center (CPC) accreditation plays an important role in the management of acute myocardial infarction (AMI). However, no evidence shows whether the outcomes of AMI patients are improved with CPC accreditation in China. Methods and Results This retrospective analysis is based on a predesigned nationwide registry, CCC‐ACS (Improving Care for Cardiovascular Disease in China‐Acute Coronary Syndrome). The primary outcome was major adverse cardiovascular events (MACE), including all‐cause death, reinfarction, stent thrombosis, stroke, and heart failure. A total of 15 344 AMI patients, from 40 CPC‐accredited hospitals, were enrolled, including 7544 admitted before and 7800 after accreditation. In propensity score matching, 6700 patients in each group were matched. The incidence of 7‐day MACE (6.7% versus 8.0%; P=0.003) and all‐cause death (1.1% versus 1.6%; P=0.021) was lower after accreditation. In multivariate adjusted mixed‐effects Cox proportional hazards models, CPC accreditation was associated with significantly decreased risk of MACE (hazard ratio: 0.78; 95% CI, 0.68–0.91) and all‐cause death (hazard ratio: 0.71; 95% CI, 0.51–0.99). The risk of MACE and all‐cause death both followed a reverse J‐shaped trend: the risk of MACE and all‐cause death decreased gradually after achieving CPC accreditation, with minimal risk occurring in the first year, but increased in the second year and after. Conclusions Based on a large‐scale national registry data set, CPC accreditation was associated with better in‐hospital outcomes for AMI patients. However, the benefits seemed to attenuate over time, and reaccreditation may be essential for maintaining AMI care quality and outcomes.
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Affiliation(s)
- Fangfang Fan
- Department of Cardiology Peking University First Hospital Beijing China
| | - Yuxi Li
- Department of Cardiology Peking University First Hospital Beijing China
| | - Yan Zhang
- Department of Cardiology Peking University First Hospital Beijing China
| | - Jianping Li
- Department of Cardiology Peking University First Hospital Beijing China
| | - Jing Liu
- Department of Epidemiology Capital Medical University Beijing Anzhen Hospital Beijing Institute of Heart, Lung & Blood Vessel Diseases Beijing China
| | - Yongchen Hao
- Department of Epidemiology Capital Medical University Beijing Anzhen Hospital Beijing Institute of Heart, Lung & Blood Vessel Diseases Beijing China
| | - Sidney C Smith
- Division of Cardiology University of North Carolina Chapel Hill NC
| | - Gregg C Fonarow
- Division of Cardiology Geffen School of Medicine at University of California Los Angeles CA
| | - Kathryn A Taubert
- Department of International Science American Heart Association Basel Switzerland
| | - Junbo Ge
- Department of Cardiology Shanghai Institute of Cardiovascular Diseases Zhongshan Hospital Fudan University Shanghai China
| | - Dong Zhao
- Department of Epidemiology Capital Medical University Beijing Anzhen Hospital Beijing Institute of Heart, Lung & Blood Vessel Diseases Beijing China
| | - Yong Huo
- Department of Cardiology Peking University First Hospital Beijing China
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16
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Abstract
Certification is a critical component of quality assurance in medicine. From the certification of individual persons, through units and up to whole hospitals, certification stimulates testing and optimization of treatment processes, thereby improving the quality of care. Minimum case numbers needed to acquire a certificate are an important and objective attribute of quality. Advantages of certification include an improved treatment of patients, structured training of new employees and enhanced cost efficiency.
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Affiliation(s)
- M Halbach
- Klinik III für Innere Medizin, Herzzentrum, Uniklinik Köln, Kerpener Straße 62, 50937, Köln, Deutschland.
| | - S Baldus
- Klinik III für Innere Medizin, Herzzentrum, Uniklinik Köln, Kerpener Straße 62, 50937, Köln, Deutschland.
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Chest Pain Unit Network in Germany: Its Effect on Patients With Acute Coronary Syndromes. J Am Coll Cardiol 2019; 69:2459-2460. [PMID: 28494983 DOI: 10.1016/j.jacc.2017.03.562] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Dornquast C, Willich SN, Reinhold T. Prevalence, Mortality, and Indicators of Health Care Supply-Association Analysis of Cardiovascular Diseases in Germany. Front Cardiovasc Med 2018; 5:158. [PMID: 30425992 PMCID: PMC6218414 DOI: 10.3389/fcvm.2018.00158] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 10/15/2018] [Indexed: 11/13/2022] Open
Abstract
Introduction: There are regional differences in the morbidity of major cardiovascular disease between the 16 federal states of Germany. An association between the morbidity and the health care supply has been described in international studies. The aim of the present analysis was to examine the relationship between the prevalence or mortality of major cardiovascular disease and several key indicators of health care supply in Germany. Methods: Life expectancy and the proportion of over 65-year old persons were included as characteristics to depict the general health. Indicators of health care supply were the number of general practitioners, internists, and cardiologists, number of internal medicine and cardiology beds, chest pain units (CPU), cardiac catheterization laboratories (CCL) and stroke units. In the form of an ecological analysis, we compared the cardiovascular disease prevalence and mortality with these indicators and performed a weighted linear regression. Results: Regional variations between the federal states were found in general health and health care supply. The regression analysis yielded significant associations of the prevalence of major cardiovascular disease with the number of internal medicine hospital beds (β = 10.042, p = 0.045), cardiologists (β = −0.689, p = 0.031), and the number of residents per chest pain unit (β = 42,730, p = 0.036). Additionally, the relationship between cardiovascular mortality and also the number of residents per chest pain unit appeared to be significant (β = 4,962, p = 0.002). For all other indicators, no significant association was observed. Conclusions: We detected regional differences in the general health and health care supply between the 16 German federal states as well as several significant associations between cardiovascular morbidity and health care supply indicators. Especially the decreasing number of cardiologists and rising number of residents per chest pain unit with an increasing prevalence of major cardiovascular disease should lead to a discussion about the structure of the Germany health care system, such as the needs-based planning mechanism of physicians. The results of this study may also aid in future development of other health care systems.
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Affiliation(s)
- Christina Dornquast
- Institute for Social Medicine, Epidemiology and Health Economics, Charité - Universitätsmedizin, Berlin, Germany
| | - Stefan N Willich
- Institute for Social Medicine, Epidemiology and Health Economics, Charité - Universitätsmedizin, Berlin, Germany
| | - Thomas Reinhold
- Institute for Social Medicine, Epidemiology and Health Economics, Charité - Universitätsmedizin, Berlin, Germany
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19
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Bock D, Senges J, Pohlmann C, Hochadel M, Münzel T, Giannitsis E, Schmitt C, Heusch G, Voigtländer T, Mudra H, Schumacher B, Darius H, Maier LS, Hailer B, Haude M, Gohlke H, Hink U. The German CPU registry: Comparison of smokers and nonsmokers. Herz 2018; 45:293-298. [PMID: 30054712 DOI: 10.1007/s00059-018-4733-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 06/22/2018] [Accepted: 06/28/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Chest pain is a major reason for admission to an internal emergency department, and smoking is a well-known risk factor for coronary artery disease (CAD) and acute coronary syndrome (ACS). The aim of this analysis is to illustrate the differences between smokers and nonsmokers presenting to German chest pain units (CPU) in regard to patient characteristics, CAD manifestation, treatment strategy, and prognosis. METHODS From December 2008 to March 2014, 13,902 patients who had a complete 3‑month follow-up were enrolled in the German CPU registry. The analysis comprised 5796 patients with ACS and documented smoking status. RESULTS Of all the patients in the CPU registry, 35.2% were smokers. Compared with nonsmokers, they were 13.5 years younger (58.2 vs. 71.7 years, p < 0.001), predominantly men (77.1% vs. 65.2%, p < 0.001), and were more frequently diagnosed with single-vessel disease (32.1% vs. 25.2%) as well as ST-elevation myocardial infarction (STEMI; 23.8% vs. 15.5%, p < 0.001). Although the Global Registry of Acute Coronary Events (GRACE) Risk Score for hospital mortality was lower in the group of smokers (106.1 vs. 123.3, p < 0.001), we did not observe any differences in CPU death (0.4% vs. 0.4%, p = 0.69) and CPU major adverse cardiac event (MACE) rates (3.8% vs 2.9%, p = 0.073) between the groups. In the 3‑month follow-up, we documented higher mortality rates in the nonsmoker group (1.9% vs. 2.9%, p = 0.035) in correlation with the GRACE Risk Score (80.3 vs. 105.2, p < 0.001). MACE rates were similar during the follow-up (3.1% vs. 4.1%, p = 0.065). CONCLUSION Observations from the German CPU registry demonstrate that smoking is a strong predictor of acute CAD manifestation early in life, especially STEMI. In spite of a lower GRACE Risk Score and fewer comorbidities, smokers had a rate of hospital mortality similar to the older group of nonsmokers.
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Affiliation(s)
- D Bock
- Department of Cardiology, Klinikum Höchst, Gotenstraße 6-8, 65929, Frankfurt am Main, Germany.
| | - J Senges
- Institut für Herzinfarktforschung, Ludwigshafen, Germany
| | - C Pohlmann
- Department of Cardiology, Klinikum Höchst, Gotenstraße 6-8, 65929, Frankfurt am Main, Germany
| | - M Hochadel
- Institut für Herzinfarktforschung, Ludwigshafen, Germany
| | - T Münzel
- Department of Cardiology, Universitätsklinik Mainz, Mainz, Germany
| | - E Giannitsis
- Department of Cardiology, Universitätsklinik Heidelberg, Heidelberg, Germany
| | - C Schmitt
- Department of Cardiology, Klinikum Karlsruhe, Karlsruhe, Germany
| | - G Heusch
- Institute for Pathophysiology, Universitätsklinik Essen, Essen, Germany
| | - T Voigtländer
- Cardiovascular Center Bethanien, Frankfurt/Main, Germany
| | - H Mudra
- Department of Cardiology, Städtisches Klinikum München, Munich, Germany
| | - B Schumacher
- 2nd Department of Medicine, Westpfalzklinikum Kaiserslautern, Kaiserslautern, Germany
| | - H Darius
- Department of Cardiology, Vivantes Hospital Neukölln, Berlin, Germany
| | - L S Maier
- Department of Cardiology, University of Regensburg, Regensburg, Germany
| | - B Hailer
- Department of Cardiology, Katholisches Klinikum Essen, Essen, Germany
| | - M Haude
- Lukaskrankenhaus, Städtische Kliniken Neuss, Neuss, Germany
| | - H Gohlke
- Universitäts-Herz-Zentrum Bad Krozingen, Bad Krozingen, Germany
| | - U Hink
- Department of Cardiology, Klinikum Höchst, Gotenstraße 6-8, 65929, Frankfurt am Main, Germany
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Lordet V, Lesbordes M, Garcia R, Varroud-Vial N, Ingrand P, Christiaens L, Levesque S. Prevalence and outcome of patients referred for chest pain with high-sensitivity troponin elevation and no diagnosis at discharge. Clin Cardiol 2018; 41:953-958. [PMID: 29802723 DOI: 10.1002/clc.22984] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Revised: 05/15/2018] [Accepted: 05/21/2018] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Specialized chest pain units appear to increase the proportion of patients with acute chest pain who are properly evaluated, but some of them remain doubtful. HYPOTHESIS The aim of this study was to evaluate the survival and occurrence of cardiovascular events in patients without diagnosis at the end of management of chest pain with high-sensitivity troponin (Tn) elevation. METHOD All consecutive patients who came to the cardiac emergency room of Poitiers University Hospital between January 1, 2014, and August 7, 2015, for chest pain and Tn elevation were included. The primary endpoint was the number of undiagnosed patients; secondary endpoints included survival and major adverse cardiac events. RESULTS A total of 1001 patients (695 male; mean age, 68 ±16 years) who had chest pain and Tn elevation were included. Median follow-up was 24.5 (IQR, 14.7-29.5) months. Forty-seven (4.7%) patients remained without diagnosis. Compared with patients with diagnosis, these patients were younger (53.6 ±19.7 years; P < 0.0001) and had less hypertension (29.8%; P < 0.0001), diabetes (4.3%; P = 0.0016), and history of coronary artery disease (6.4%; P < 0.0001). No patients died or experienced MACE in 6-month follow-up. Survival curves showed the probability of survival was excellent, not only at 6 months, but also at 36 months (P = 0.0025). CONCLUSIONS Less than 5% of patients referred for chest pain and with high-sensitivity Tn elevation remained without diagnosis after adapted care in the chest pain unit. Their 6-month prognosis was excellent.
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Affiliation(s)
- Vincent Lordet
- Department of Cardiology, CHU of Poitiers, Poitiers, France
| | | | | | | | - Pierre Ingrand
- INSERM CIC-1402, Department of Epidemiology and Biostatistics, Poitiers University, Poitiers, France
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21
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Sörensen NA, Neumann JT, Ojeda F, Schäfer S, Magnussen C, Keller T, Lackner KJ, Zeller T, Karakas M, Münzel T, Blankenberg S, Westermann D, Schnabel RB. Relations of Sex to Diagnosis and Outcomes in Acute Coronary Syndrome. J Am Heart Assoc 2018; 7:e007297. [PMID: 29525782 PMCID: PMC5907542 DOI: 10.1161/jaha.117.007297] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 01/24/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND The atypical presentation of women with acute coronary syndrome (ACS) has been related to delayed diagnosis and treatment, which may explain worse outcome compared with men. METHODS AND RESULTS We analyzed pooled data of 2520 patients of 2 prospective cohorts in terms of differences in presentation and management of women and men suggestive of ACS. Using logistic regression, we established 2 diagnostic models and tested their diagnostic performance in both sexes separately. Sex-specific differences in management of patients with ACS were ascertained and a 2-year follow-up was performed. Women were older than men (median 67 versus 61 years, P=0.001), had more often dyspnea (22% versus 18%, P=0.024), nausea or vomiting (26% versus 16%, P=0.001) and radiating chest pain (47% versus 40%, P=0.001). Classical risk factors (smoking, diabetes mellitus, dyslipidemia or known coronary artery disease) were less frequent in women. Diagnostic models showed no significant sex-related differences in diagnostic performance in a "first contact" setting (medical history and symptoms) or after "complete triage" (including ECG and biomarkers). Women with ACS underwent coronary angiography (73.8% versus 84.3%, P<0.001) and revascularization (53.8% versus 70.1%, P<0.001) less frequently. Two-year incidence of myocardial infarction and death was similar in both sexes, but revascularization and cardiac rehospitalization were more frequent in men. CONCLUSIONS In a large cohort of patients with suspected ACS, sex differences in clinical presentation did not impair diagnostic accuracy. Two-year outcomes were comparable. Our findings suggest a benefit of chest pain units to minimize sex differences in ACS management and prognosis. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov. Unique identifiers: NCT02355457 (BACC), NCT03227159 (stenoCardia).
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Affiliation(s)
- Nils Arne Sörensen
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Johannes Tobias Neumann
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Francisco Ojeda
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany
| | - Sarina Schäfer
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Christina Magnussen
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Till Keller
- Department of Cardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
- German Center for Cardiovascular Research, Partner Site RheinMain, Hamburg, Germany
| | - Karl J Lackner
- German Center for Cardiovascular Research, Partner Site RheinMain, Hamburg, Germany
- Department of Clinical Chemistry and Laboratory Medicine, University Medical Center of the Johannes Gutenberg-University Mainz, Germany
| | - Tanja Zeller
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Mahir Karakas
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Thomas Münzel
- German Center for Cardiovascular Research, Partner Site RheinMain, Hamburg, Germany
- Center for Cardiology, University Medical Center of the Johannes Gutenberg-University Mainz, Germany
| | - Stefan Blankenberg
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Dirk Westermann
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Renate B Schnabel
- Department of General and Interventional Cardiology, University Heart Center Hamburg, Germany
- German Center for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
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Characterization and referral patterns of ST-elevation myocardial infarction patients admitted to chest pain units rather than directly to catherization laboratories. Data from the German Chest Pain Unit Registry. Int J Cardiol 2017; 231:31-35. [PMID: 28189192 DOI: 10.1016/j.ijcard.2016.12.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 11/29/2016] [Accepted: 12/05/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Direct transfer to the catheterization laboratory for primary percutaneous coronary intervention (PCI) is standard of care for patients with ST-segment elevation myocardial infarction (STEMI). Nevertheless, a significant number of STEMI-patients are initially treated in chest pain units (CPUs) of admitting hospitals. Thus, it is important to characterize these patients and to define why an important deviation from recommended clinical pathways occurs and in particular to quantify the impact of deviation on critical time intervals. METHODS AND RESULTS 1679 STEMI patients admitted to a CPU in the period from 2010 to 2015 were enrolled in the German CPU registry (8.5% of 19,666). 55.9% of the patients were delivered by an emergency medical system (EMS), 16.1% transferred from other hospitals and 15.2% referred by a general practitioner (GP). 12.7% were self-referrals. 55% did not get a pre-hospital ECG. Compared to the EMS, referral by GPs markedly delayed critical time intervals while a pre-hospital ECG demonstrating ST-segment elevation reduced door-to-balloon time. When compared to STEMI patients (n=21,674) enrolled in the ALKK-registry, CPU-STEMI patients had a lower risk profile, their treatment in the CPU was guideline-conform and in-hospital mortality was low (1.5%). CONCLUSIONS CPU-STEMI patients represent a numerically significant group because a pre-hospital ECG was not documented. Treatment in the CPU is guideline-conform and the intra-hospital mortality is low. The lack of a pre-hospital ECG and admission via the GP substantially delay critical time intervals suggesting that in patients with symptoms suggestive an ACS, the EMS should be contacted and not the GP.
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Wächter C, Markus B, Schieffer B. [Cardiac causes of chest pain]. Internist (Berl) 2017; 58:8-21. [PMID: 27981367 DOI: 10.1007/s00108-016-0165-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Because of the life-threatening character and a high prevalence in emergency rooms, cardiac causes are important differential diagnoses of acute chest pain with the need for rapid clarification. In this context the working diagnosis "acute coronary syndrome" (ACS) plays a major role. In a synopsis of the clinical presentation, medical history, electrocardiogram and analysis of cardiac biomarkers, ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI) and unstable angina pectoris can be specified as entities of ACS. The treatment of ACS consists of an immediate anti-ischemic therapy, anti-thrombotic therapy and invasive coronary diagnostics with subsequent interventional or operative revascularization therapy. The timing of invasive management is essentially determined by the individual patient risk, with the exception of STEMI where interventional revascularization must be undertaken within 120 min of diagnosis. In this context the GRACE 2.0 and TIMI risk score have become established as reliable tools. Another rare but fatal cause of acute chest pain is aortic dissection. An abrupt onset of tearing and sharp chest pains, deficits in pulse as well as the presence of high-risk factors, such as advanced age, arterial hypertension, atherosclerosis, known collagenosis and previous aortic or coronary artery procedures are highly indicative for aortic dissection and additional diagnostic imaging and the highly sensitive D‑dimer should be undertaken. Additionally, inflammatory diseases, such as pericarditis and myocarditis can be associated with chest pains and mimic the character of ACS and should also be considered in the differential diagnostics.
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Affiliation(s)
- C Wächter
- Klinik für Kardiologie, Angiologie und internistische Intensivmedizin, Universitäres Herzzentrum Marburg, Uniklinikum Gießen und Marburg, Standort Marburg, Baldingerstr., 35043, Marburg, Deutschland
| | - B Markus
- Klinik für Kardiologie, Angiologie und internistische Intensivmedizin, Universitäres Herzzentrum Marburg, Uniklinikum Gießen und Marburg, Standort Marburg, Baldingerstr., 35043, Marburg, Deutschland
| | - B Schieffer
- Klinik für Kardiologie, Angiologie und internistische Intensivmedizin, Universitäres Herzzentrum Marburg, Uniklinikum Gießen und Marburg, Standort Marburg, Baldingerstr., 35043, Marburg, Deutschland.
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Claeys MJ, Ahrens I, Sinnaeve P, Diletti R, Rossini R, Goldstein P, Czerwińska K, Bueno H, Lettino M, Münzel T, Zeymer U. Editor’s Choice-The organization of chest pain units: Position statement of the Acute Cardiovascular Care Association. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2017; 6:203-211. [DOI: 10.1177/2048872617695236] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Affiliation(s)
- Marc J Claeys
- Department of Cardiology, Antwerp University Hospital, Belgium
| | - Ingo Ahrens
- Cardiology and Angiology I, Heart Centre, University of Freiburg, Germany
| | - Peter Sinnaeve
- Department of Cardiology, University Hospital of Leuven, Belgium
| | - Roberto Diletti
- Department of Cardiology, Thoraxcentre, Rotterdam, The Netherlands
| | - Roberta Rossini
- Department of Cardiology, Papa Giovanni XXIII Hospital, Bergano, Italy
| | | | - Kasia Czerwińska
- Intensive Cardiac Care Unit, American Heart of Poland, Bielsko-Biała, Poland
| | - Héctor Bueno
- Department of Cardiology, University Hospital 12th Octobre, Madrid, Spain
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - Maddalena Lettino
- Department of Cardiovascular Disease, Humanitas Research Hospital, Milano, Italy
| | - Thomas Münzel
- Department of Cardiology and Intensive Care, University Hospital Mainz, Germany
| | - Uwe Zeymer
- Department of Cardiology, Germany
- Heart Centre Ludwigshafen, Ludwigshafen, Germany
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Breuckmann F, Olligs J, Hinrichs L, Koopmann M, Lichtenberg M, Böse D, Fischer D, Eckardt L, Waltenberger J, Garvey JL. Coronary Artery Calcium as an Independent Surrogate Marker in the Risk Assessment of Patients With Atrial Fibrillation and an Intermediate Pretest Likelihood for Coronary Artery Disease Admitted to a German Chest Pain Unit. Clin Cardiol 2016; 39:157-64. [PMID: 27001202 DOI: 10.1002/clc.22506] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 11/18/2015] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND About 10% of patients admitted to a chest pain unit (CPU) exhibit atrial fibrillation (AF). HYPOTHESIS To determine whether calcium scores (CS) are superior over common risk scores for coronary artery disease (CAD) in patients presenting with atypical chest pain, newly diagnosed AF, and intermediate pretest probability for CAD within the CPU. METHODS In 73 subjects, CS was related to the following risk scores: Global Registry of Acute Coronary Events (GRACE) score, including a new model of a frequency-normalized approach; Thrombolysis In Myocardial Infarction score; European Society of Cardiology Systematic Coronary Risk Evaluation (SCORE); Framingham risk score; and Prospective Cardiovascular Münster Study score. Revascularization rates during index stay were assessed. RESULTS Median CS was 77 (interquartile range, 1-270), with higher values in men and the left anterior descending artery. Only the modified GRACE (ρ = 0.27; P = 0.02) and the SCORE (ρ = 0.39; P < 0.005) were significantly correlated with CS, whereas the GRACE (τ = 0.21; P = 0.04) and modified GRACE (τ = 0.23; P = 0.02) scores were significantly correlated with percentile groups. Only the CS significantly discriminated between those with and without stenosis (P < 0.01). CONCLUSIONS Apart from modified GRACE score, overall correlations between risk scores and calcium burden, as well as revascularization rates during index stay, were low. By contrast, the determination of CS may be used as an additional surrogate marker in risk stratification in AF patients with intermediate pretest likelihood for CAD admitted to a CPU.
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Affiliation(s)
- Frank Breuckmann
- Department of Cardiology, Arnsberg Medical Center, Arnsberg, Germany
| | - Jan Olligs
- Department of Cardiovascular Medicine, University of Münster, Münster, Germany
| | - Liane Hinrichs
- Department of Anesthesiology, Arnsberg Medical Center, Arnsberg, Germany
| | - Matthias Koopmann
- Department of Cardiovascular Medicine, University of Münster, Münster, Germany
| | | | - Dirk Böse
- Department of Cardiology, Arnsberg Medical Center, Arnsberg, Germany
| | - Dieter Fischer
- Department of Cardiovascular Medicine, University of Münster, Münster, Germany
| | - Lars Eckardt
- Department of Cardiovascular Medicine, University of Münster, Münster, Germany
| | | | - J Lee Garvey
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina
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26
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Breuckmann F, Hochadel M, Voigtländer T, Haude M, Schmitt C, Münzel T, Giannitsis E, Mudra H, Heusch G, Schumacher B, Barth S, Schuler G, Hailer B, Walther D, Senges J. On versus off-hour care of patients with acute coronary syndrome and persistent ST-segment elevation in certified German chest pain units. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2016; 6:3-9. [PMID: 26714975 DOI: 10.1177/2048872615624845] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Regional healthcare projects improve the off-hour care of patients with acute coronary syndromes and persistent ST-segment elevation myocardial infarction (STEMI). To analyse differences in quality of care between on and off-hour care of STEMI patients admitted to certified German chest pain units. METHODS A total of 1107 STEMI patients from the German chest pain unit registry were enrolled. Analyses comprised critical time intervals (symptoms to first medical contact (FMC), FMC to admission, symptoms to admission, symptoms to balloon, FMC to balloon, door to balloon times) and major adverse cardiac and cerebrovascular events at follow-up. RESULTS 54.8% of patients were admitted off-hours. Symptoms to admission (2:28 (1:28-5:20 h) vs. 3:16 h (1:35-8:06 h), P<0.001), symptoms to FMC (1:15 h (0:33-3:00 h) vs. 2:00 h (0:40-6:46 h), P<0.001) and FMC to admission intervals (0:45 h (0:30-1:20 h) vs. 0:52 h (0:32-1:35 h), P=0.09) were shorter during off-hours. Percutaneous revascularisation rates were high and without difference between on and off-hours (95.5% vs. 96.8%, P=0.30). Door to balloon times were significantly less during on-hours (0:32 h (0:18-1:06 h) vs. 0:44 h (0:23-1:20 h), P<0.01) without negative impact on the proportion of patients with a door to balloon time of <60 min (72.6% vs. 68.4%, P=0.19), symptoms to balloon (3:49 h (2:12-10:46 h) vs. 3:30 h (2:04-7:41 h), P=0.08) or FMC to balloon times (1:26 h (0:56-2:22 h) vs. 1:30 h (1:03-2:29 h), P=0.14). Major adverse cardiac and cerebrovascular event rates did not differ significantly between on and off-hours (log-rank test P=0.36). CONCLUSIONS The German chest pain unit network ensures rapid and structured preclinical and in-hospital care independent from the circadian variation of admission. Slower door to balloon times off-hours are compensated by faster symptoms to admission or symptoms to FMC intervals. Further efforts should focus on patient awareness programmes on-hours and STEMI alarming tracks off-hours.
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Affiliation(s)
| | | | | | | | - Claus Schmitt
- 5 Clinic for Cardiology and Angiology, Municipal Hospital Karlsruhe, Germany
| | - Thomas Münzel
- 6 2nd Department of Medicine, Johannes Gutenberg-University Mainz, Germany
| | | | - Harald Mudra
- 8 Department of Cardiology, Pneumology, Internal Intensive Care Medicine, Städtisches Klinikum München GmbH, Germany
| | - Gerd Heusch
- 9 Institute for Pathophysiology, University Duisburg-Essen, Germany
| | | | - Sebastian Barth
- 11 Department of Cardiology, Herz- und Gefäß-Klinik GmbH, Germany
| | | | - Birgit Hailer
- 13 Department of Cardiology, Catholic Clinics Essen-Northwest, Germany
| | - Dirk Walther
- 14 2nd Department of Medicine, HELIOS Kreiskrankenhaus Gotha/Ohrdruf, Germany
| | - Jochen Senges
- 2 Institute for Myocardial Infarction Research, Germany
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Fischer D, Remberg F, Böse D, Lichtenberg M, Kümpers P, Lebiedz P, Pavenstädt HJ, Waltenberger J, Breuckmann F. How rapid is rapid? Exemplary results of real-life rapid rule-out troponin timing in troponin-positive acute coronary syndromes without persistent ST-segment elevation in two contrasting German chest pain unit facilities. Eur J Med Res 2016; 21:11. [PMID: 26984277 PMCID: PMC4794842 DOI: 10.1186/s40001-016-0206-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Accepted: 03/07/2016] [Indexed: 11/30/2022] Open
Abstract
Aim To analyse the timing of cardiac troponin (cTn) measurements in high-risk and cTn-positive acute coronary syndromes without persistent ST-segment elevation (NSTE-ACS) in two structurally different German chest pain units (CPUs), contrasting an urban university maximum care and a rural regional primary care facility. Methods All patients encoded as NSTEMI during the year 2013 were retrospectively enrolled in two centres: site (I)—centre of maximum care in an urban university setting and site (II)—centre of primary care in a rural regional care setting. Data acquisition included time intervals from admission to baseline cTn and first and second cTn control as well as type and timing of invasive management. Results The median times (site I vs. site II) from admission to cTn result announcement were 26.5 vs. 33.0 min (p = 0.02) for baseline, 4 vs. 4 h (p = 0.43) for the first and 11.0 vs. 16.5 h (p = 0.03) for the second control. Timely announcement, as recommended by guidelines, was available in 86.9 % at baseline, 59.4 % for the first or 41.1 % for the second cTn control. Rates and timing of invasive management were independent from the time point of positive cTn announcement (p = 0.51 and p = 0.68, respectively). Conclusions German CPUs provide timely identification of cTn-positive patients in a narrow and guideline-adherent time frame using a rapid rule-out protocol. Especially, baseline and early cTn timing was comparable between the urban university maximum care and the rural regional primary care facility without relevant impact on guideline-conforming invasive management, underlining the high standard of care in those highly professional institutions.
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Affiliation(s)
- Dieter Fischer
- Department of Cardiology and Angiology, University Hospital Münster, Albert-Schweitzer-Campus 1, A1, 48149, Münster, Germany.
| | | | - Dirk Böse
- Department of Cardiology, Arnsberg Medical Center, Arnsberg, Germany
| | | | - Philipp Kümpers
- Department of General Internal Medicine, Nephrology and Rheumatology, University Hospital Münster, Münster, Germany
| | - Pia Lebiedz
- Department of Cardiology and Angiology, University Hospital Münster, Albert-Schweitzer-Campus 1, A1, 48149, Münster, Germany
| | - Hermann-Joseph Pavenstädt
- Department of General Internal Medicine, Nephrology and Rheumatology, University Hospital Münster, Münster, Germany
| | - Johannes Waltenberger
- Department of Cardiology and Angiology, University Hospital Münster, Albert-Schweitzer-Campus 1, A1, 48149, Münster, Germany
| | - Frank Breuckmann
- Department of Cardiology, Arnsberg Medical Center, Arnsberg, Germany
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Timing of percutaneous coronary intervention in troponin-negative patients with acute coronary syndrome without persistent ST-segment elevation: preliminary results and status quo in German chest pain units. Crit Pathw Cardiol 2015; 14:7-11. [PMID: 25679082 DOI: 10.1097/hpc.0000000000000032] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Management of acute coronary syndromes without persistent ST-segment elevation (NSTE-ACS) and unstable angina pectoris (UAP) remains challenging. The study aimed to analyze the current management of UAP patients in German chest pain units focussing on the different time lines of invasive strategy. METHODS A total of 1400 UAP patients admitted to a certified chest pain unit were enrolled. Analyses of high-risk criteria with indication for invasive management and of 3-month clinical outcomes were performed by subgrouping UAP patients to immediate and early invasive (<8 hours), early elective invasive (8-24 hours), late elective invasive (24-72 hours) strategy, and without percutaneous coronary intervention (PCI). RESULTS Coronary angiography was performed in 60.6% of the UAP patients, whereas PCI was necessary in 37%. Only 1.4% of the UAP patients obtained immediate PCI within the first 120 minutes. In 16.9%, patients received PCI within the first day of hospitalization or even within the first 8 hours after admission in another 7.7%, although the Global Registry of Acute Coronary Events (GRACE) score at admission was below 140. In the remaining 12.4% of the UAP patients, PCI was performed within 24-72 hours after admission. Those patients exhibited a higher prevalence of secondary risk markers than those with conservative treatment regimen. CONCLUSIONS To date, almost two-third of UAP patients at intermediate to high risk receive rapid invasive regimen within the first 24 hours after admission. Oncoming studies will have to analyze its overall guideline-adherence and resulting differences in major adverse events.
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Guideline-conforming timing of invasive management in troponin-positive or high-risk ACS without persistent ST-segment elevation in German chest pain units. Urban university maximum care vs. rural regional primary care. Herz 2015; 41:151-8. [PMID: 26407695 DOI: 10.1007/s00059-015-4354-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Revised: 07/03/2015] [Accepted: 08/18/2015] [Indexed: 12/22/2022]
Abstract
AIM This study aimed to analyze guideline adherence in the timing of invasive management for myocardial infarction without persistent ST-segment elevation (NSTEMI) in two exemplary German centers, comparing an urban university maximum care facility and a rural regional primary care facility. METHODS All patients diagnosed as having NSTEMI during 2013 were retrospectively enrolled in two centers: (1) site I, a maximum care center in an urban university setting, and (b) site II, a primary care center in a rural regional care setting. Data acquisition included time intervals from admission to invasive management, risk criteria, rate of intervention, and medical therapy. RESULTS The median time from admission to coronary angiography was 12.0 h (site I) or 17.5 h (site II; p = 0.17). Guideline-adherent timing was achieved in 88.1 % (site I) or 82.9 % (site II; p = 0.18) of cases. Intervention rates were high in both sites (site I-75.5 % vs. site II-75.3 %; p = 0.85). Adherence to recommendations of medical therapy was high and comparable between the two sites. CONCLUSION In NSTEMI or high-risk acute coronary syndromes without persistent ST-segment elevation, guideline-adherent timing of invasive management was achieved in about 85 % of cases, and was comparable between urban maximum and rural primary care settings. Validation by the German Chest Pain Unit Registry including outcome analysis is required.
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Post F, Gori T, Giannitsis E, Darius H, Baldus S, Hamm C, Hambrecht R, Hofmeister HM, Katus H, Perings S, Senges J, Münzel T. Criteria of the German Society of Cardiology for the establishment of chest pain units: update 2014. Clin Res Cardiol 2015; 104:918-28. [PMID: 26150114 PMCID: PMC4623090 DOI: 10.1007/s00392-015-0888-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 06/23/2015] [Indexed: 12/22/2022]
Abstract
Since 2008, the German Cardiac Society (DGK) has been establishing a network of certified chest pain units (CPUs). The goal of CPUs was and is to carry out differential diagnostics of acute or newly occurring chest pain of undetermined origin in a rapid and goal-oriented manner and to take immediate therapeutic measures. The basis for the previous certification process was criteria that have been established and published by the task force on CPUs. These criteria regulate the spatial and technical requirements and determine diagnostic and therapeutic strategies in patients with chest pain. Furthermore, the requirements for the organization of CPUs and the training requirements for the staff of a CPU are defined. The certification process is carried out by the DGK; currently, 225 CPUs are certified and 139 CPUs have been recertified after running for a period of 3 years. The certification criteria have now been revised and updated according to new guidelines.
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Affiliation(s)
- Felix Post
- Katholisches Klinikum Koblenz Montabaur, Koblenz, Germany
| | - Tommaso Gori
- II. Medizinische Klinik und Poliklinik für Kardiologie, Angiologie und internistische Intensivmedizin, Universitätsmedizin Mainz, Langenbeckstr. 1, 55131, Mainz, Germany
| | | | - Harald Darius
- Department für Kardiologie, Innere Medizin und Intensivmedizin, Vivantes-Klinikum Neukölln, Berlin, Germany
| | - Stephan Baldus
- Klinikum III für Innere Medizin Uniklinik Köln, Cologne, Germany
| | | | - Rainer Hambrecht
- Klinik für Kardiologie und Angiologie, Herzzentrum Bremen, Bremen, Germany
| | | | - Hugo Katus
- Klinik für KardiologieAngiologie und Pneumonologie, Heidelberg, Germany
| | | | - Jochen Senges
- Institut für Herzinfarktforschung, Ludwigshafen, Germany
| | - Thomas Münzel
- II. Medizinische Klinik und Poliklinik für Kardiologie, Angiologie und internistische Intensivmedizin, Universitätsmedizin Mainz, Langenbeckstr. 1, 55131, Mainz, Germany.
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Breuckmann F, Burt DR, Melching K, Erbel R, Heusch G, Senges J, Garvey JL. Chest Pain Centers: A Comparison of Accreditation Programs in Germany and the United States. Crit Pathw Cardiol 2015; 14:67-73. [PMID: 26102016 DOI: 10.1097/hpc.0000000000000041] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVE The implementation of chest pain centers (CPC)/units (CPU) has been shown to improve emergency care in patients with suspected cardiac ischemia. METHODS In an effort to provide a systematic and specific standard of care for patients with acute chest pain, the Society of Cardiovascular Patient Care (SCPC) as well as the German Cardiac Society (GCS) introduced criteria for the accreditation of specialized units. RESULTS To date, 825 CPCs in the United States and 194 CPUs in Germany have been successfully certified by the SCPC or GCS, respectively. Even though there are differences in the accreditation processes, the goals are quite similar, focusing on enhanced operational efficiencies in the care of the acute coronary syndrome patients, reduced time delays, improved diagnostic and therapeutic strategies using adapted standard operating procedures, and increased medical as well as community awareness by the implementation of nationwide standardized concepts. In addition to national efforts, both societies have launched international initiatives, accrediting CPCs/CPU in the Middle East and China (SCPC) and Switzerland (GCS). CONCLUSION Enhanced collaboration among international bodies interested in promoting high quality care might extend the opportunity for accreditation of facilities that treat cardiovascular patients, with national programs designed to meet local needs and local healthcare system requirements.
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Affiliation(s)
- Frank Breuckmann
- From the *Department of Cardiology, Arnsberg Medical Center, Arnsberg, Germany; †Department of Emergency Medicine, University of Virginia, Charlottesville, VA; ‡Society of Cardiovascular Patient Care, Dublin, OH; §Department of Cardiology, West German Heart and Vascular Center Essen, University Duisburg-Essen, Essen, Germany; ¶Institute for Pathophysiology, West German Heart and Vascular Center Essen, University Duisburg-Essen, Essen, Germany; ‖Institute for Myocardial Infarction Research Foundation Ludwigshafen, University of Heidelberg, Heidelberg, Germany; and **Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC
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Kriterien der Deutschen Gesellschaft für Kardiologie – Herz- und Kreislaufforschung für „Chest Pain Units“. KARDIOLOGE 2015. [DOI: 10.1007/s12181-014-0646-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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The German CPU Registry: Dyspnea independently predicts negative short-term outcome in patients admitted to German Chest Pain Units. Int J Cardiol 2015; 181:88-95. [DOI: 10.1016/j.ijcard.2014.11.199] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2014] [Revised: 10/28/2014] [Accepted: 11/24/2014] [Indexed: 01/21/2023]
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Breuckmann F, Hochadel M, Darius H, Giannitsis E, Münzel T, Maier LS, Schmitt C, Schumacher B, Heusch G, Voigtländer T, Mudra H, Senges J. Guideline-adherence and perspectives in the acute management of unstable angina - Initial results from the German chest pain unit registry. J Cardiol 2014; 66:108-13. [PMID: 25497278 DOI: 10.1016/j.jjcc.2014.11.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Revised: 10/22/2014] [Accepted: 11/12/2014] [Indexed: 12/22/2022]
Abstract
BACKGROUND We investigated the current management of unstable angina pectoris (UAP) in certified chest pain units (CPUs) in Germany and focused on the European Society of Cardiology (ESC) guideline-adherence in the timing of invasive strategies or choice of conservative treatment options. More specifically, we analyzed differences in clinical outcome with respect to guideline-adherence. METHOD Prospective data from 1400 UAP patients were collected. Analyses of high-risk criteria with indication for invasive management and 3-month clinical outcome data were performed. Guideline-adherence was tested for a primarily conservative strategy as well as for percutaneous coronary intervention (PCI) within <24 and <72h after admission. RESULTS Overall guideline-conforming management was performed in 38.2%. In UAP patients at risk, undertreatment caused by an insufficient consideration of risk criteria was obvious in 78%. Reciprocally, overtreatment in the absence of adequate risk markers was performed in 27%, whereas a guideline-conforming primarily conservative strategy was chosen in 73% of the low-risk patients. Together, the 3-month major adverse coronary and cerebrovascular events (MACCE) were low (3.6%). Nonetheless, guideline-conforming treatment was even associated with significantly lower MACCE rates (1.6% vs. 4.0%, p<0.05). CONCLUSION The data suggest an inadequate adherence to ESC guidelines in nearly two thirds of the patients, particularly in those patients at high to intermediate risk with secondary risk factors, emphasizing the need for further attention to consistent risk profiling in the CPU and its certification process.
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Affiliation(s)
- Frank Breuckmann
- Department of Cardiology, Arnsberg Medical Center, Arnsberg, Germany.
| | - Matthias Hochadel
- Institute for Myocardial Infarction Research Foundation Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Harald Darius
- Department of Cardiology, Angiology and Intensive Care Medicine, Vivantes-Klinikum Neukölln, Berlin, Germany
| | | | - Thomas Münzel
- 2nd Department of Medicine, Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Lars S Maier
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Claus Schmitt
- Clinic for Cardiology and Angiology, Municipal Hospital Karlsruhe, Karlsruhe, Germany
| | | | - Gerd Heusch
- Institute for Pathophysiology, University Duisburg-Essen, Essen, Germany
| | | | - Harald Mudra
- Department of Cardiology, Pneumology and Internal Intensive Care Medicine, Klinikum Neuperlach, Städtisches Klinikum München GmbH, Munich, Germany
| | - Jochen Senges
- Institute for Myocardial Infarction Research Foundation Ludwigshafen, University of Heidelberg, Heidelberg, Germany
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35
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Peters RJG. The history of the cardiac emergency room, and the patient's history. Neth Heart J 2014; 22:550-1. [PMID: 25376774 PMCID: PMC4391191 DOI: 10.1007/s12471-014-0625-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Affiliation(s)
- R J G Peters
- Department of Cardiology, F3-236, Academic Medical Center, PO Box 22660, 1100 DD, Amsterdam, the Netherlands,
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36
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[Chest pain units or chest pain algorithm?]. Med Klin Intensivmed Notfmed 2014; 109:495-503. [PMID: 25330873 DOI: 10.1007/s00063-013-0342-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 09/01/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND A large number of patients present to the emergency department (ED) for evaluation of acute chest pain. About 10-15% are caused by acute myocardial infarction (MI), and over 50% of cases are due to noncardiac reasons. Further improvement for chest pain evaluation appears necessary. OBJECTIVES What are current options to improve chest pain evaluation in Germany? METHODS A selective literature search was performed using the following terms: "chest pain", "emergency department", "acute coronary syndrome" and "chest pain evaluation". RESULTS AND DISCUSSION A working group of the German Society of Cardiology published recommendations for infrastructure, equipment and organisation of chest pain units in Germany, which should be separated from the ED of hospitals and be under the leadership of a cardiologist. A symptom-based decision for acute care would be preferable if all differential diagnoses of diseases could be managed by one medical specialty: However, all four main symptoms of patients with acute MI (chest pain, acute dyspnea, abdominal pain, dizziness) are also caused by diseases of different specialties. Evaluation and treatment of acute chest pain by representatives of one specialty would lead to over- or undertreatment of affected patients. Therefore we suggest a multidisciplinary evaluation of patients with acute chest pain including representatives of emergency and critical care physicians, cardiologists, internists, geriatricians, family physicians, premedics and emergency nurses. Definition of key indicators of performance and institutionalized feedback will help to further improve quality of care.
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Le Meur A, Lauque D, Carrié D, Galinier M, Juchet H, Charpentier S. Évaluation d’un algorithme de prise en charge des syndromes coronariens non ST+ aux urgences. ANNALES FRANCAISES DE MEDECINE D URGENCE 2014. [DOI: 10.1007/s13341-013-0391-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Illmann A, Riemer T, Erbel R, Giannitsis E, Hamm C, Haude M, Heusch G, Maier LS, Münzel T, Schmitt C, Schumacher B, Senges J, Voigtländer T, Mudra H. Disease distribution and outcome in troponin-positive patients with or without revascularization in a chest pain unit: results of the German CPU-Registry. Clin Res Cardiol 2013; 103:29-40. [DOI: 10.1007/s00392-013-0619-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2013] [Accepted: 09/11/2013] [Indexed: 10/26/2022]
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Nowak B, Giannitsis E, Riemer T, Münzel T, Haude M, Maier LS, Schmitt C, Schumacher B, Mudra H, Hamm C, Senges J, Voigtländer T. Self-referral to chest pain units: results of the German CPU-registry. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2013; 1:312-9. [PMID: 24062922 DOI: 10.1177/2048872612463542] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Accepted: 09/13/2012] [Indexed: 12/24/2022]
Abstract
BACKGROUND Chest pain units (CPUs) are increasingly established in emergency cardiology services. With improved visibility of CPUs in the population, patients may refer themselves directly to these units, obviating emergency medical services (EMS). Little is known about characteristics and outcomes of self-referred patients, as compared with those referred by EMS. Therefore, we described self-referral patients enrolled in the CPU-registry of the German Cardiac Society and compared them with those referred by EMS. METHODS AND RESULTS From 2008 until 2010, the prospective CPU-registry enrolled 11,581 consecutive patients. Of those 3789 (32.7%) were self-referrals (SRs), while 7792 (67.3%) were referred by EMS. SR-patients were significantly younger (63.6 vs. 70.1 years), had less prior myocardial infarction or coronary artery bypass surgery, but more previous percutaneous coronary interventions (PCIs). Acute coronary syndromes were diagnosed less frequently in the SR-patients (30.3 vs. 46.9%; p<0.0001). SR-patients showed ST-segment changes in their initial ECG in 19.6% of cases. EMS-patients underwent more coronary angiographies (60.0 vs. 47.5%; p<0.0001), while SR-patients underwent more stress tests (11.3 vs. 7.8%; p<0.001). PCI was performed in 32.6% of the EMS- and in 24.0% of the SR-group (p<0.0001). CONCLUSION These data demonstrate that patients who contact a CPU as a self-referral are younger, less severely ill and have more non-coronary problems than those calling an emergency medical service. Nevertheless, 30% of self-referral patients had an acute coronary syndrome.
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Affiliation(s)
- Bernd Nowak
- CCB, Cardioangiologisches Centrum Bethanien, Frankfurt am Main, Germany
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Maier LS, Darius H, Giannitsis E, Erbel R, Haude M, Hamm C, Hasenfuss G, Heusch G, Mudra H, Münzel T, Schmitt C, Schumacher B, Senges J, Voigtländer T, Schüttert JB. The German CPU Registry: Comparison of troponin positive to troponin negative patients. Int J Cardiol 2013; 168:1651-3. [DOI: 10.1016/j.ijcard.2013.03.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Accepted: 03/09/2013] [Indexed: 10/27/2022]
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The predictive value of the exercise ECG for major adverse cardiac events in patients who presented with chest pain in the emergency department. Clin Res Cardiol 2013; 102:305-12. [DOI: 10.1007/s00392-012-0535-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Accepted: 12/11/2012] [Indexed: 10/27/2022]
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Sonigra A, Lawlor J, Roberts L. Evaluation of an Australian chest pain assessment unit. Intern Med J 2012; 42:1292-6. [DOI: 10.1111/j.1445-5994.2012.02799.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2011] [Accepted: 03/05/2012] [Indexed: 11/28/2022]
Affiliation(s)
- A. Sonigra
- The Townsville Hospital; Townsville Queensland Australia
| | - J. Lawlor
- The Townsville Hospital; Townsville Queensland Australia
| | - L. Roberts
- The Townsville Hospital; Townsville Queensland Australia
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Tölg R, Zeymer U, Birkemeyer R, Wessely R, Eggebrecht H, Bocksch W, Schneider S, Richardt G, Hamm C. Cardiogoniometry as a diagnostic tool in patients with acute coronary syndromes: results of the CGM@ACS trial. Clin Res Cardiol 2012; 101:727-36. [PMID: 22485015 PMCID: PMC3426668 DOI: 10.1007/s00392-012-0452-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Accepted: 03/23/2012] [Indexed: 11/26/2022]
Abstract
BACKGROUND Cardiogoniometry (CGM) is a novel electrocardiac method utilising computer-assisted three-dimensional information on cardiac potentials. OBJECTIVE To investigate the potential of CGM in discriminating non-ST-segment elevation acute coronary syndrome (NSTE-ACS) and relevant coronary stenosis upon hospital admission by prospectively comparing its sensitivity, specificity and accuracy against those of a single troponin test and a 12-lead ECG performed on admission DESIGN A multicenter prospective observational trial. SETTING Eight interventional cardiac centres in Germany. PATIENTS A cohort of 216 patients (mean age 67 years, 34.7 % female) who presented with acute chest pain or dyspnoea without ST-segment elevation and were scheduled for coronary angiography within 72 h of admission. INTERVENTION Pre-angiography screening by CGM, troponin test, 12-lead ECG MAIN OUTCOME MEASURES: ECG, troponin and CGM on admission compared with final diagnosis of NSTE-ACS or relevant diameter stenosis ≥70 % verified by an independent review board and an angiographic core laboratory. RESULTS NSTE-ACS was finally confirmed in 162 cases, whereas the remaining 54 cases without proof of NSTE-ACS served as controls. Diagnostic sensitivity for NSTE-ACS was 28, 50 and 69 % and specificity 78, 96 and 54 % for first ECG, serial troponin and first CGM, respectively. Accuracy was 40, 62 and 65 %. The sensitivity of the tests to detect relevant coronary stenosis (n = 126) was 32, 53 and 74 %, respectively. The sensitivity of CGM to detect NSTE-ACS (65 %) or relevant stenosis (71 %) was high even in patients with normal troponin and ECG. CONCLUSIONS CGM can detect NSTE-ACS at first medical contact. CGM in conjunction with traditional markers, 12-lead ECG and troponin may effectively aid early decision making in patients presenting with acute chest pain.
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Affiliation(s)
- Ralph Tölg
- Herzzentrum, Segeberger Kliniken GmbH, Bad Segeberg, Germany.
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Pre- and early in-hospital procedures in patients with acute coronary syndromes: first results of the "German chest pain unit registry". Clin Res Cardiol 2012; 101:983-91. [PMID: 22829016 DOI: 10.1007/s00392-012-0487-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Accepted: 06/08/2012] [Indexed: 01/18/2023]
Abstract
BACKGROUND In an attempt to improve the treatment of patients with acute coronary syndromes (ACS), a network of certified chest pain units (CPUs) has been recently established in Germany. METHODS Data from patients admitted between December 2008 and September 2011 for ACS in 40 certified CPUs participating in the registry were prospectively collected. RESULTS A total of 5,457 patients was admitted for ACS; 798 patients (14.6 %) were diagnosed with an ST-elevation myocardial infarction (STEMI), 2,244 (41.1 %) with a non-ST-elevation myocardial infarction (NSTEMI), and 2,415 (44.3 %) with unstable angina. The mean time to first medical contact was 2:08 h for STEMI patients. A pre-hospital ECG was available in 23.8 % of all ACS patients. Importantly, evidence of ST-segment elevation was present in 79.7 % of the STEMI patients already in this pre-hospital ECG. As many as 76.6 % of the patients, independently of their symptoms and final diagnosis, received an ECG within 10 min of reaching the CPU. 98.2 % of STEMI patients underwent invasive diagnostics, with an in-hospital delay as little as 31 (11-75) min. CONCLUSION The establishment of a nation-wide network of certified CPUs optimizes the medical treatment of patients with ACS while providing an ideal infrastructure to evaluate and improve, both on a nation-wide and a single center scale, the adherence to guidelines. The median delay between symptom onset and first medical contact remains high. Although performed relatively rarely, a pre-hospital ECG facilitates earlier diagnosis of a STEMI in a large majority of patients. The introduction of CPUs minimizes in-hospital delays and exploits the benefit of invasive diagnostics and treatment.
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Chest Pain Units in Deutschland. Notf Rett Med 2012. [DOI: 10.1007/s10049-012-1596-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Keller T, Tzikas S, Scheiba O, Krahn U, Post F, Arnolds S, Blankenberg S, Warnholtz A, Münzel T, Genth-Zotz S. Reduktion der stationären Verweildauer bei Patienten mit akutem Koronarsyndrom durch Einrichtung einer Chest Pain Unit. Herz 2011; 37:301-7. [DOI: 10.1007/s00059-011-3544-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Accepted: 09/29/2011] [Indexed: 11/28/2022]
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Influence of algorithm-based analgesia and sedation in patients after sudden cardiac arrest. Clin Res Cardiol 2011; 101:175-83. [PMID: 22048697 DOI: 10.1007/s00392-011-0378-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Accepted: 10/27/2011] [Indexed: 12/17/2022]
Abstract
PURPOSE The aim of this study was to analyse the effect of an algorithm-based analgesic-sedative management on mechanical ventilation time and length of stay in a cardiological ICU with critical ill patients after sudden cardiac arrest. METHODS We examined 100 patients after successful resuscitation in a retrospective-prospective single-centre trial by introducing an algorithm-based sedation management. Demographic data, severity of illness classified by APACHE II score (Acute Physiology and Chronic Health Evaluation II), neurological outcome and data for mechanical ventilation time and length of stay were acquired for both groups. RESULTS We found a shorter ventilation time for young patients without severe illness, whereby significant longer ventilation time was observed for patients with higher APACHE II score. Between both groups, we found no significant differences in mechanical ventilation time and length of stay. CONCLUSIONS Our results demonstrate a tendency towards a reduction of mechanical ventilation time for patients without severe illness after sudden cardiac arrest achieved by implementation of a new sedation management, whereby significant longer ventilation time was observed for severe ill patients. Because of lack of statistical significance of our present study, a randomized study with sufficient power is necessary to demonstrate positive effects of a standardized sedation management and its influence on severity of illness.
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Ottervanger JP. Chest pain without ST elevation: a continuing challenge. Neth Heart J 2011; 19:317-8. [DOI: 10.1007/s12471-011-0172-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Gu YL, Voors AA, Zijlstra F, Hillege HL, Struck J, Masson S, Vago T, Anker SD, van den Heuvel AFM, van Veldhuisen DJ, de Smet BJGL. Comparison of the temporal release pattern of copeptin with conventional biomarkers in acute myocardial infarction. Clin Res Cardiol 2011; 100:1069-76. [PMID: 21766239 PMCID: PMC3222827 DOI: 10.1007/s00392-011-0343-y] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2011] [Accepted: 07/01/2011] [Indexed: 01/02/2023]
Abstract
Background Early detection of acute myocardial infarction (AMI) using cardiac biomarkers of myocardial necrosis remains limited since these biomarkers do not rise within the first hours from onset of AMI. We aimed to compare the temporal release pattern of the C-terminal portion of provasopressin (copeptin) with conventional cardiac biomarkers, including creatine kinase isoenzyme (CK-MB), cardiac troponin T (cTnT), and high-sensitivity cTnT (hs-cTnT), in patients with ST-elevation AMI. Methods We included 145 patients undergoing successful primary percutaneous coronary intervention (PCI) for a first ST-elevation AMI presenting within 12 h of symptom onset. Blood samples were taken on admission and at four time points within the first 24 h after PCI. Results In contrast to all other markers, copeptin levels were already elevated on admission and were higher with a shorter time from symptom onset to reperfusion and lower systolic blood pressure. Copeptin levels peaked immediately after symptom onset at a maximum of 249 pmol/L and normalized within 10 h. In contrast, CK-MB, cTnT, and hs-cTnT peaked after 14 h from symptom onset at a maximum of 275 U/L, 5.75 μg/L, and 4.16 μg/L, respectively, and decreased more gradually. Conclusions Copeptin has a distinct release pattern in patients with ST-elevation AMI, peaking within the first hour after symptom onset before conventional cardiac biomarkers and falling to normal ranges within the first day. Further studies are required to determine the exact role of copeptin in AMI suspects presenting within the first hours after symptom onset.
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Affiliation(s)
- Youlan L. Gu
- Department of Cardiology, Thorax Center, University Medical Center Groningen, University of Groningen, Hanzeplein 1, PO Box 30001, 9700 RB Groningen, The Netherlands
| | - Adriaan A. Voors
- Department of Cardiology, Thorax Center, University Medical Center Groningen, University of Groningen, Hanzeplein 1, PO Box 30001, 9700 RB Groningen, The Netherlands
| | - Felix Zijlstra
- Thorax Center, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Hans L. Hillege
- Department of Cardiology, Thorax Center, University Medical Center Groningen, University of Groningen, Hanzeplein 1, PO Box 30001, 9700 RB Groningen, The Netherlands
| | - Joachim Struck
- Research Department, B.R.A.H.M.S. GmbH (Part of ThermoFisher Scientific), Hennigsdorf, Germany
| | - Serge Masson
- Department of Cardiovascular Research, Instituto Mario Negri, Milan, Italy
| | - Tarcisio Vago
- Laboratory of Endocrinology, Ospedale Luigi Sacco, Milan, Italy
| | - Stefan D. Anker
- Applied Cachexia Research, Department of Cardiology, Charité, Campus Virchow-Klinikum, Berlin, Germany
| | - Ad F. M. van den Heuvel
- Department of Cardiology, Thorax Center, University Medical Center Groningen, University of Groningen, Hanzeplein 1, PO Box 30001, 9700 RB Groningen, The Netherlands
| | - Dirk J. van Veldhuisen
- Department of Cardiology, Thorax Center, University Medical Center Groningen, University of Groningen, Hanzeplein 1, PO Box 30001, 9700 RB Groningen, The Netherlands
| | - Bart J. G. L. de Smet
- Department of Cardiology, Thorax Center, University Medical Center Groningen, University of Groningen, Hanzeplein 1, PO Box 30001, 9700 RB Groningen, The Netherlands
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