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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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Heusch G. Myocardial ischemia/reperfusion: Translational pathophysiology of ischemic heart disease. MED 2024; 5:10-31. [PMID: 38218174 DOI: 10.1016/j.medj.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 11/27/2023] [Accepted: 12/12/2023] [Indexed: 01/15/2024]
Abstract
Ischemic heart disease is the greatest health burden and most frequent cause of death worldwide. Myocardial ischemia/reperfusion is the pathophysiological substrate of ischemic heart disease. Improvements in prevention and treatment of ischemic heart disease have reduced mortality in developed countries over the last decades, but further progress is now stagnant, and morbidity and mortality from ischemic heart disease in developing countries are increasing. Significant problems remain to be resolved and require a better pathophysiological understanding. The present review attempts to briefly summarize the state of the art in myocardial ischemia/reperfusion research, with a view on both its coronary vascular and myocardial aspects, and to define the cutting edges where further mechanistic knowledge is needed to facilitate translation to clinical practice.
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Affiliation(s)
- Gerd Heusch
- Institute for Pathophysiology, West German Heart and Vascular Center, University of Duisburg-Essen, Essen, Germany.
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Breuckmann F, Settelmeier S, Rassaf T, Post F, Haerer W, Bauersachs J, Mudra H, Voigtländer T, Senges J, Münzel T, Giannitsis E. Survey of clinical practice pattern in Germany's certified chest pain units : Adherence to the European Society of Cardiology guidelines on non-ST-segment elevation acute coronary syndrome. Herz 2022; 47:543-552. [PMID: 34755215 PMCID: PMC8577645 DOI: 10.1007/s00059-021-05079-2] [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] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 09/16/2021] [Accepted: 10/16/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND We aimed to analyze the 2020 standard of care in certified German chest pain units (CPU) with a special focus on non-ST-segment elevation acute coronary syndrome (NSTE-ACS) through a voluntary survey obtained from all certified units, using a prespecified questionnaire. METHODS The assessment included the collection of information on diagnostic protocols, risk assessment, management and treatment strategies in suspected NSTE-ACS, the timing of invasive therapy in non-ST-segment elevation myocardial infarction (NSTEMI), and the choice of antiplatelet therapy. RESULTS The response rate was 75%. Among all CPUs, 77% are currently using the European Society of Cardiology (ESC) 0/3‑h high-sensitive troponin protocol, and only 20% use the ESC 0/1‑h high-sensitive troponin protocol as a default strategy. Conventional ergometry is still the commonly performed stress test with a utilization rate of 47%. Among NSTEMI patients, coronary angiography is planned within 24 h in 96% of all CPUs, irrespective of the day of the week. Prasugrel is the P2Y12 inhibitor of choice in ST-segment elevation myocardial infarction (STEMI), but despite the impact of the ISAR-REACT 5 trial on selection of antiplatelet therapy, ticagrelor is still favored over prasugrel in NSTE-ACS. If triple therapy is used in NSTE-ACS with atrial fibrillation, it is maintained up to 4 weeks in 51% of these patients. CONCLUSION This survey provides evidence that Germany's certified CPUs ensure a high level of guideline adherence and quality of care. The survey also identified areas in need of improvement such as the high utilization rate of stress electrocardiogram (ECG).
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Affiliation(s)
- Frank Breuckmann
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Duisburg-Essen, Essen, Germany.
| | - Stephan Settelmeier
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Duisburg-Essen, Essen, Germany
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Duisburg-Essen, Essen, Germany
| | - Felix Post
- Department of Cardiology, Katholisches Klinikum Koblenz-Montabaur, Koblenz, Germany
| | | | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Harald Mudra
- Heart and Vascular Center Munich Maffeistraße and Nymphenburg (Klinikum 3. Orden), Munich, 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
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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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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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Breuckmann F, Settelmeier S, Rassaf T, Hochadel M, Nowak B, Voigtländer T, Giannitsis E, Senges J, Münzel T. Unexpected high level of severe events even in low-risk profile chest pain unit patients. Herz 2021; 47:374-379. [PMID: 34463785 PMCID: PMC9355921 DOI: 10.1007/s00059-021-05064-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 04/25/2021] [Accepted: 07/20/2021] [Indexed: 11/29/2022]
Abstract
AIMS Early heart attack awareness programs are thought to increase efficacy of chest pain units (CPU) by providing live-saving information to the community. We hypothesized that self-referral might be a feasible alternative to activation of emergency medical services (EMS) in selected chest pain patients with a specific low-risk profile. METHODS AND RESULTS In this observational registry-based study, data from 4743 CPU patients were analyzed for differences between those with or without severe or fatal prehospital or in-unit events (out-of-hospital cardiac arrest and/or in-unit death, resuscitation or ventricular tachycardia). In order to identify a low-risk subset in which early self-referral might be recommended to reduce prehospital critical time intervals, the Global Registry of Acute Coronary Events (GRACE) score for in-hospital mortality and a specific low-risk CPU score developed from the data by multivariate regression analysis were applied and corresponding event rates were calculated. Male gender, cardiac symptoms other than chest pain, first onset of symptoms and a history of myocardial infarction, heart failure or cardioverter defibrillator implantation increased propensity for critical events. Event rates within the low-risk subsets varied from 0.5-2.8%. Those patients with preinfarction angina experienced fewer events. CONCLUSIONS When educating patients and the general population about angina pectoris symptoms and early admission, activation of EMS remains recommended. Even in patients without any CPU-specific risk factor, self-referral bears the risk of severe or fatal pre- or in-unit events of 0.6%. However, admission should not be delayed, and self-referral might be feasible in patients with previous symptoms of preinfarction angina.
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Affiliation(s)
- Frank Breuckmann
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Duisburg-Essen, Essen, Germany.
| | - Stephan Settelmeier
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Duisburg-Essen, Essen, Germany
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Duisburg-Essen, Essen, Germany
| | - Matthias Hochadel
- Institute for Myocardial Infarction Research Foundation, Ludwigshafen, Germany
| | - Bernd Nowak
- Cardioangiologisches Centrum Bethanien, Frankfurt am Main, 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
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Capacity changes in German certified chest pain units during COVID-19 outbreak response. Clin Res Cardiol 2020; 109:1469-1475. [PMID: 32476041 PMCID: PMC7261510 DOI: 10.1007/s00392-020-01676-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 05/19/2020] [Indexed: 01/17/2023]
Abstract
Background We sought to determine structure and changes in organisation and bed capacities of certified German chest pain units (CPU) in response to the emergency plan set-up as a response to the SARS-CoV-2 pandemic. Methods and results The study was conducted in the form of a standardised telephone interview survey in certified German CPUs. Analyses comprised the overall setting of the CPU, bed capacities, possibilities for ventilation, possible changes in organisation and resources, chest pain patient admittance, overall availability of CPUs and bail-out strategies. The response rate was 91%. Nationwide, CPU bed capacities decreased by 3% in the early phase of COVID-19 pandemic response, exhibiting differences within and between the federal states. Pre-pandemic and pandemic bed capacities stayed below 1 CPU bed per 50,000 inhabitants. 97% of CPUs were affected by internal reorganisation pandemic plans at variable extent. While we observed a decrease of CPU beds within an emergency room (ER) set-up and on intermediate care units (ICU), beds in units being separated from ER and ICU were even increased in numbers. Conclusions Certified German CPUs are able to maintain adequate coverage for chest pain patients in COVID-19 pandemic despite structural changes. However, at this time, it appears important to add operating procedures during pandemic outbreaks to the certification criteria of forthcoming guidelines either at the individual CPU level or more centrally steered by the German Cardiac Society or the European Society of Cardiology.
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Gori T, Lelieveld J, Münzel T. Perspective: cardiovascular disease and the Covid-19 pandemic. Basic Res Cardiol 2020; 115:32. [PMID: 32277299 PMCID: PMC7146013 DOI: 10.1007/s00395-020-0792-4] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 04/06/2020] [Indexed: 12/23/2022]
Abstract
We summarize the cardiovascular risks associated with Covid-19 pandemic, discussing the risks for both infected and non-infected patients.
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Affiliation(s)
- Tommaso Gori
- Department of Cardiology, Universitätsmedizin Mainz and DZHK Standort Rhein-Main, Langenbeckstrasse 1, 55131, Mainz, Germany.
| | | | - Thomas Münzel
- Department of Cardiology, Universitätsmedizin Mainz and DZHK Standort Rhein-Main, Langenbeckstrasse 1, 55131, Mainz, Germany
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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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Breuckmann F, Hochadel M, Grau AJ, Giannitsis E, Münzel T, Senges J. Quality benchmarks for chest pain units and stroke units in Germany. Herz 2020; 46:89-93. [PMID: 31970463 DOI: 10.1007/s00059-019-04881-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Revised: 10/05/2019] [Accepted: 12/06/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Chest pain units (CPUs) and stroke units (SUs) provide specialized multidisciplinary in-hospital management for acute chest pain and ischemic stroke. We analyzed exemplary equivalent quality benchmarks in both concepts. MATERIAL AND METHODS Data from the German CPU registry (2012-2015; 45 certified CPUs, 5881 patients) were compared with data from the SU registry of Rhineland-Palatinate (2011-2015; 29 SUs; 40,380 patients). Parameters comprised demographics, symptoms, diagnosis, medication, critical time intervals, therapeutics, and in-unit outcome. RESULTS Non-ST-segment elevation myocardial infarction (47.4%) and ischemic stroke (63.0%) were the most frequent entities. An electrocardiogram was performed on average within 7 min in CPUs, cranial imaging within 49 min in SUs. The mean time interval from admission until coronary intervention or lysis was 42 min or 57 min, respectively. Rates of antiplatelet therapy (90.1% vs. 96.0%), brain imaging, and coronary angiography were high (99.3% vs. 81.1%) and the mortality was low (0.8% for CPUs vs. 3.6% for SUs). The length of stay was shorter in CPUs (1.5 days vs. 4.4 days). CONCLUSION As reimbursement for emergency medicine in Germany was recently rearranged, quality benchmarking has gained incremental importance. Mandatory joint quality measurement in both concepts ensuring gap analysis and process improvement is encouraged.
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Affiliation(s)
- Frank Breuckmann
- Department of Cardiology, Herz-Jesu-Krankenhaus Dernbach, Südring 8, 56428, Dernbach, Germany.
| | - Matthias Hochadel
- Institute for Myocardial Infarction Research Foundation Ludwigshafen, University of Heidelberg, Heidelberg, Germany
| | - Armin J Grau
- Department of Neurology, Klinikum Ludwigshafen, Ludwigshafen am Rhein, Germany
| | - Evangelos Giannitsis
- Department of Internal Medicine III, Heidelberg University Hospital, Heidelberg, Germany
| | - Thomas Münzel
- Cardiology I, Center for Cardiology, University Medical Center Mainz, Mainz, Germany
| | - Jochen Senges
- Institute for Myocardial Infarction Research Foundation Ludwigshafen, University of Heidelberg, Heidelberg, Germany
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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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Community Outreach in Terms of Early Heart Attack Care as a New Way of Thinking in Chest Pain Center/Unit Care Giving-Commentary on the German Chest Pain Unit Network. Crit Pathw Cardiol 2018; 16:167-168. [PMID: 29135626 DOI: 10.1097/hpc.0000000000000127] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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