The accuracy of general practitioners' clinical assessment of chest pain patients

Characteristics of patients with acute myocardial infarction contacting primary healthcare before hospitalisation: a cross-sectional study

Background

The characteristics of patients with on-going myocardial infarction (MI) contacting the primary healthcare (PHC) centre before hospitalisation are not well known. Prompt diagnosis is crucial in patients with MI, but many patients delay seeking medical care. The aims of this study was to 1) describe background characteristics, symptoms, actions and delay times in patients contacting the PHC before hospitalisation when falling ill with an acute MI, 2) compare those patients with acute MI patients not contacting the PHC, and 3) explore factors associated with a PHC contact in acute MI patients.

Methods

This was a cross-sectional multicentre study, enrolling consecutive patients with MI within 24 hours of admission to hospital from Nov 2012 until Feb 2014.

Results

A total of 688 patients with MI, 519 men and 169 women, were included; the mean age was 66±11 years. One in five people contacted PHC instead of the recommended emergency medical services (EMS), and 94% of these patients experienced cardinal symptoms of an acute MI; i.e., chest pain, and/or radiating pain in the arms, and/or cold sweat. Median delay time from symptom-onset-to-decision-to-seek-care was 2:15 hours in PHC patients and 0:40 hours in non-PHC patients (p<0.01). The probability of utilising the PHC before hospitalisation was associated with fluctuating symptoms (OR 1.74), pain intensity (OR 0.90) symptoms during off-hours (OR 0.42), study hospital (OR 3.49 and 2.52, respectively, for two of the county hospitals) and a final STEMI diagnosis (OR 0.58).

Conclusions

Ambulance services are still underutilized in acute MI patients. A substantial part of the patients contacts their primary healthcare centre before they are diagnosed with MI, although experiencing cardinal symptoms such as chest pain. There is need for better knowledge in the population about symptoms of MI and adequate pathways to qualified care. Knowledge and awareness amongst primary healthcare professionals on the occurrence of MI patients is imperative.

The cost-utility of point-of-care troponin testing to diagnose acute coronary syndrome in primary care

Background

The added value of using a point-of-care (POC) troponin test in primary care to rule out acute coronary syndrome (ACS) is debated because test sensitivity is inadequate early after symptom onset. This study investigates the potential cost-utility of diagnosing ACS by a general practitioner (GP) when a POC troponin test is available versus GP assessment only.

Methods

A patient-level simulation model was developed, representing a hypothetical cohort of the Dutch population (>35 years) consulting the GP with chest complaints. All health related consequences as well as cost consequences were included. Both symptom duration, selection of patients in whom the POC troponin test is performed, and test performance at different time points were incorporated. Health outcomes were expressed as Quality-Adjusted Life Years (QALYs). The main outcome parameters involve the effect of POC troponin testing on (in)correct hospital referrals, QALYs, and costs.

Results

The POC troponin strategy decreases the referral rate in non-ACS patients from 38.46% to 31.85%. Despite a small increase in non-referral among ACS patients from 0.22% to 0.27%, the overall health effect is negligible. Costs will decrease with €77.25/patient (95% CI €-126.81 to €-33.37).

Conclusions

The POC troponin strategy is likely cost-saving, by reducing hospital referrals. The small increase in missed ACS patients can be partly explained by conservative assumptions used in the analysis. Besides, current developments in POC troponin tests will likely further improve their diagnostic performance. Therefore, future prospective studies are warranted to investigate whether those developments make the POC troponin test to a safe and cost-effective diagnostic tool for diagnosing ACS in general practices.

Electronic supplementary material

The online version of this article (doi:10.1186/s12872-017-0647-6) contains supplementary material, which is available to authorized users.

Causes of chest pain in primary care--a systematic review and meta-analysis

Aim

To investigate the frequencies of different and relevant underlying etiologies of chest pain in general practice.

Methods

We systematically searched PubMed and EMBASE. Two reviewers independently rated the eligibility of publications and assessed the risk of bias of included studies. We extracted data to calculate the relative frequencies of different underlying conditions and investigated the variation across studies using forest plots, I², tau², and prediction intervals. With respect to unexplained heterogeneity, we provided qualitative syntheses instead of pooled estimates.

Results

We identified 11 eligible studies comprising about 6500 patients. The overall risk of bias was rated as low in 6 studies comprising about 3900 patients. The relative frequencies of different conditions as the underlying etiologies of chest pain reported by these studies ranged from 24.5 to 49.8% (chest wall syndrome), 13.8 to 16.1% (cardiovascular diseases), 6.6 to 11.2% (stable coronary heart disease), 1.5 to 3.6% (acute coronary syndrome/myocardial infarction), 10.3 to 18.2% (respiratory diseases), 9.5 to 18.2% (psychogenic etiologies), 5.6 to 9.7% (gastrointestinal disorders), and 6.0 to 7.1% (esophageal disorders).

Conclusion

This information may be of practical value for general practitioners as it provides the pre-test probabilities for a range of underlying diseases and may be suitable to guide the diagnostic process.

Chest pain out-of-hours - an interview study of primary care physicians' diagnostic approach, tolerance of risk and attitudes to hospital admission

Background

Acute chest pain constitutes a considerable diagnostic challenge outside hospitals. This will often lead to uncertainty in choosing the right management, and the physicians’ approach may be influenced by their knowledge of diagnostic measures and their tolerance of risk. The aim of this study was to investigate primary care physicians’ diagnostic approach, tolerance of risk and attitudes to hospital admission in patients with acute chest pain out-of-hours in Norwegian primary care.

Methods

Data were registered prospectively from four Norwegian casualty clinics. Data from structured telephone interviews with 100 physicians shortly after a consultation with a patient presenting at the casualty clinic with “chest pain” were analysed. Tolerance of risk was measured by the Pearson Risk Scale and the Tolerance of Risk Scale, the latter developed for this study.

Results

“Patient history and symptoms” was considered the most important, and “negative ECG” and “effect of sublingual nitroglycerine” the least important aspects in the diagnostic approach. There were no significant differences in length of experience or gender when testing “risk avoiders” against the rest. Almost all physicians felt that their risk assessment out-of-hours was reasonably good, and felt reasonably safe, but only 50% agreed with the statement “I don’t worry about my decisions after I’ve made them”. Concerning chest pain patients only, 51% of the physicians were worried about complaints being made about them, 75% agreed that admitting someone to hospital put patients in danger of being “over-tested”, and 51% were more likely to admit the patient if the patient herself wanted to be admitted.

Conclusions

Physicians working out-of-hours showed considerable differences in their diagnostic approach, and not all physicians diagnose patients with chest pain according to current guidelines and evidence. Continuous medical education must focus on the diagnostic approach in patients with chest pain in primary care and empowerment of physicians through training and emphasis on risk assessment and “tolerance of risk”.

Should general practitioners order troponin tests?

Cardiac troponin I and T are the preferred biomarkers for assessing myocardial injury, and the timing of troponin testing is fundamental to its clinical utility. There are arguments for and against the use of troponin testing in the community, and the stance that general practitioners should never order a troponin test can be considered an oversimplification. GPs have a generally sufficient understanding of the test for use in primary care, and have a better understanding of false-negative troponin test results than false-positive results. We suggest that hospitalisation, rather than troponin testing, should be the default option for patients with symptoms suggestive of acute coronary syndrome. A single troponin test is reasonable in primary care to exclude the possibility of acute myocardial infarction in asymptomatic low-risk patients whose symptoms resolved at least 12 hours prior. GPs should factor in the complex logistics of troponin testing in the community before ordering a troponin test: results need to be accurate and timely, and might be obtained at a time of day when it is difficult to contact the doctor or the patient.

The approach to patients with possible cardiac chest pain

Chest pain is a common reason for presentation in hospital emergency departments and general practice. Some patients presenting with chest pain to emergency departments and, to a lesser extent, general practice will be found to have a life-threatening cause, but most will not. The challenge is to identify those who do in a safe, timely and cost-effective manner. An acute coronary syndrome cannot be excluded on clinical grounds alone. In patients with ongoing symptoms of chest pain, without an obvious other cause, ST-segment-elevation myocardial infarction should be excluded with a 12-lead electrocardiogram at the first available opportunity. Significant recent advances in the clinical approach to patients with acute chest pain, including better understanding of risk stratification, increasingly sensitive cardiac biomarkers and new non-invasive tests for coronary disease, can help clinicians minimise the risk of unexpected short-term adverse cardiac events. An approach that integrates these advances is needed to deliver the best outcomes for patients with chest pain. All hospital emergency departments should adopt such a strategic approach, and general practitioners should be aware of when and how to access these facilities.

Point-of-Care Troponin T Testing in the Management of Patients with Chest Pain in the Swedish Primary Care

Objective. To investigate the diagnostic accuracy and clinical benefit of point-of-care Troponin T testing (POCT-TnT) in the management of patients with chest pain. Design. Observational, prospective, cross-sectional study with followup. Setting. Three primary health care (PHC) centres using POCT-TnT and four PHC centres not using POCT-TnT in the southeast of Sweden. Patients. All patients ≥35 years old, contacting one of the primary health care centres for chest pain, dyspnoea on exertion, unexplained weakness, and/or fatigue with no other probable cause than cardiac, were included. Symptoms should have commenced or worsened during the last seven days. Main Outcome Measures. Emergency referrals, patients with acute myocardial infarctions (AMI), or unstable angina (UA) within 30 days of study enrolment. Results. 25% of the patients from PHC centres with POCT-TnT and 43% from PHC centres without POCT-TnT were emergently referred by the GP (P = 0.011 ). Seven patients (5.5%) from PHC centres with POCT-TnT and six (8.8%) from PHC centres without POCT-TnT were diagnosed as AMI or UA (P = 0.369). Two patients with AMI or UA from PHC centres with POCT-TnT were judged as missed cases in primary health care. Conclusion. The use of POCT-TnT may reduce emergency referrals but probably at the cost of an increased risk to miss patients with AMI or UA.

Socio-demographic variation in chest pain incidence and subsequent coronary heart disease in primary care in the United Kingdom

BACKGROUND

We know little about socio-demographic differences in chest pain presenting to primary care and subsequent coronary heart disease (CHD) diagnosis.

METHODS

We conducted a cohort study with 198,209 patients aged 30 years and over with a first episode of chest pain, using data from 339 general practices in The Health Improvement Network (THIN) primary care database during 1997-2007. We calculated incidence of chest pain and subsequent CHD by age, gender and quintiles of Townsend area deprivation score.

RESULTS

Chest pain incidence was 19.6/1000 person years at risk (PYAR, 95% CI 19.5-19.7). Incidence rose with age and increasing deprivation, with minimal gender differences. The incidence of CHD in the year following chest pain in primary care was 96.6/1000 PYAR (95% CI 95.1-98.0). There were significant interactions with age/deprivation and gender/deprivation on subsequent CHD diagnosis. The effect of deprivation was less for those over 60 years, and greater for younger women. Women in their 30s with chest pain in deprived areas had 8.77 times (95% CI 3.34-23.06) the CHD incidence compared to those in the most affluent areas. The absolute risk difference was small (8/1000 PYAR, 95% CI 4.5-11.5/1000 PYAR).

CONCLUSIONS

There was a modestly greater incidence of chest pain in primary care in more deprived areas compared to the least deprived areas. There were interactions between age, gender and deprivation on subsequent CHD diagnosis, with the greatest effect of deprivation on CHD diagnosis seen in younger women. This observation suggests the need for targeting health promotion and CHD prevention among younger women in deprived areas.

The diagnosis of coronary heart disease in a low-prevalence setting: follow-up data from patients whose CHD was misdiagnosed by their family doctors

BACKGROUND

The diagnosis of coronary heart disease (CHD) is a challenge for primary care physicians (PCPs). We studied the further course of 57 patients who presented to their PCPs with chest pain and were initially misdiagnosed as not having CHD as the cause of chest pain.

METHODS

The 57 misdiagnosed patients were among 1,249 consecutive patients aged 35 and above who presented with chest pain to 74 different PCPs (35% of the 209 PCPs initially invited to participate in the study). For each patient, the PCPs recorded the initial history and physical findings and the course over the ensuing six months. An independent interdisciplinary reference panel reviewed all of the data and retrospectively determined each patient's most likely cause of chest pain at the time of inclusion in the study.

RESULTS

For 405 patients (32.4%), the PCPs rated the probability that CHD was the cause of chest pain at 0 to 5%. The reference panel retrospectively diagnosed CHD as the cause of chest pain in 180 patients. The PCPs correctly diagnosed CHD as the cause of chest pain in 123 (68.3%) of these patients and failed to diagnose CHD as the cause of chest pain in 57 of them (31.7%). 26 (45.6%) of the 57 misdiagnosed patients had a history of CHD. Even when the diagnosis of CHD as the cause of chest pain was missed, the PCPs often ordered an ECG (42 of 57 patients, or 73.7%) or referred the patient to a cardiologist or internist (20 of 57 patients, or 35.1%).

CONCLUSION

Primary care physicians diagnose CHD with moderate sensitivity. Even when they initially fail to make the diagnosis, they often order further tests and consultations that ultimately lead to a correct diagnosis of CHD.

Accuracy of general practitioners' assessment of chest pain patients for coronary heart disease in primary care: cross-sectional study with follow-up

AIM

To estimate how accurately general practitioners' (GP) assessed the probability of coronary heart disease in patients presenting with chest pain and analyze the patient management decisions taken as a result.

METHODS

During 2005 and 2006, the cross-sectional diagnostic study with a delayed-type reference standard included 74 GPs in the German state of Hesse, who enrolled 1249 consecutive patients presenting with chest pain. GPs recorded symptoms and findings for each patient on a report form. Patients and GPs were contacted 6 weeks and 6 months after the patients' visit to the GP. Data on chest complaints, investigations, hospitalization, and medication were reviewed by an independent panel, with coronary heart disease being the reference condition. Diagnostic properties (sensitivity, specificity, and predictive values) of the GPs' diagnoses were calculated.

RESULTS

GPs diagnosed coronary heart disease with the sensitivity of 69% (95% confidence interval [CI], 62-75) and specificity of 89% (95% CI, 87-91), and acute coronary syndrome with the sensitivity of 50% (95% CI, 36-64) and specificity of 98% (95% CI, 97-99). They assumed coronary heart disease in 245 patients, 41 (17%) of whom were referred to the hospital, 77 (31%) to a cardiologist, and 162 (66%) to electrocardiogram testing.

CONCLUSIONS

GPs' evaluation of chest pain patients, based on symptoms and signs alone, was not sufficiently accurate for diagnosing or excluding coronary heart disease or acute coronary syndrome.

Phase-contrast MRI and 3D-CISS versus contrast-enhanced MR cisternography for the detection of spontaneous third ventriculostomy

PURPOSE

To compare the diagnostic efficacies of phase-contrast MRI (PC-MRI) and three-dimensional constructive interference in steady-state (3D-CISS) sequence for the detection of spontaneous third ventriculostomy (STV) on the basis of contrast-enhanced MR cisternography (MRC).

PATIENTS AND METHODS

Eleven obstructive hydrocephalus patients with clinically-radiologically suspected STV and ten controls were examined by PC-MRI, 3D-CISS and MRC. PC-MRI and 3D-CISS sequence were applied to view the third ventricle and basal cisterns. Following injection of 0.5-1ml intrathecal Gd-DTPA injection, postcontrast MRC images were obtained in three planes. Presence of STV was scored as follows: grade 0, no existence of STV; grade 1, STV present. Results of PC-MRI and 3D-CISS were compared with the MRC findings.

RESULTS

In PC-MRI, five patients were assessed as grade 0 and six cases grade 1. As a result of 3D-CISS sequence, eight cases were evaluated as grade 0 and three cases grade 1. Based on MRC, nine cases were assessed as grade 0 and two cases grade 1. False positivity was found in four cases by PC-MRI and in one case by 3D-CISS. The sensitivity, specificity and accuracy of PC-MRI and 3D-CISS sequence regarding demonstration of STV, were 100, 100, 56, 89, 64, and 91% respectively.

DISCUSSION

PC-MRI and 3D-CISS are helpful in confirming the STV. PC-MRI and 3D-CISS should be the first preference. If PC-MRI and 3D-CISS give negative results, then MRC is not required. MRC should be performed on patients who demonstrate suspected STV findings on PC-MRI and 3D-CISS sequences. MRC may prevent false positive results.

Accuracy of general practitioners' assessment of chest pain patients for coronary heart disease in primary care: cross-sectional study with follow-up

AIM

To estimate how accurately general practitioners' (GP) assessed the probability of coronary heart disease in patients presenting with chest pain and analyze the patient management decisions taken as a result.

METHODS

During 2005 and 2006, the cross-sectional diagnostic study with a delayed-type reference standard included 74 GPs in the German state of Hesse, who enrolled 1249 consecutive patients presenting with chest pain. GPs recorded symptoms and findings for each patient on a report form. Patients and GPs were contacted 6 weeks and 6 months after the patients' visit to the GP. Data on chest complaints, investigations, hospitalization, and medication were reviewed by an independent panel, with coronary heart disease being the reference condition. Diagnostic properties (sensitivity, specificity, and predictive values) of the GPs' diagnoses were calculated.

RESULTS

GPs diagnosed coronary heart disease with the sensitivity of 69% (95% confidence interval [CI], 62-75) and specificity of 89% (95% CI, 87-91), and acute coronary syndrome with the sensitivity of 50% (95% CI, 36-64) and specificity of 98% (95% CI, 97-99). They assumed coronary heart disease in 245 patients, 41 (17%) of whom were referred to the hospital, 77 (31%) to a cardiologist, and 162 (66%) to electrocardiogram testing.

CONCLUSIONS

GPs' evaluation of chest pain patients, based on symptoms and signs alone, was not sufficiently accurate for diagnosing or excluding coronary heart disease or acute coronary syndrome.

Phase-contrast MRI and 3D-CISS versus contrast-enhanced MR cisternography on the evaluation of the aqueductal stenosis

INTRODUCTION

In the current study, we aimed to compare the diagnostic efficacies of phase-contrast magnetic resonance imaging (PC-MRI) and three-dimensional constructive interference in steady-state (3D-CISS) sequence over detection of aqueductal stenosis (AS) on the basis of contrast-enhanced magnetic resonance cisternography (MRC).

METHODS

Twenty-five patients with clinically and radiologically suspected AS were examined by PC-MRI, 3D-CISS, and MRC. Axial-sagittal PC-MRI and sagittal 3D-CISS were applied to view the cerebral aqueduct. Following injection of 0.5-1 ml intrathecal gadolinium diethylenetriamine pentaacetic acid (Gd-DTPA) injection, postcontrast MRC images were obtained in three planes in early and late phases. Aqueductal patency was scored as follows: grade 0, normal; grade 1, partial narrowing; and grade 2, complete obstruction. Results of PC-MRI and 3D-CISS were compared with the findings of MRC.

RESULTS

In PC-MRI, seven cases were assessed as grade 0, 16 cases grade 1, and two cases grade 2. As a result of 3D-CISS sequence, eight cases were evaluated as grade 0, 12 cases grade 1, and five cases grade 2. Based on MRC, nine cases were assessed as grade 0, whereas nine and seven cases were evaluated to be grades 1 and 2, respectively. Five cases that demonstrated partial patency in PC-MRI or 3D-CISS showed complete obstruction by MRC.

CONCLUSION

PC-MRI is helpful in confirming the AS. However, positive flow does not necessarily exclude the existence of AS. 3D-CISS sequence provides excellent cerebrospinal fluid-to-aqueduct contrast, allowing detailed study of the anatomic features of the aqueduct. MRC should be performed on patients who demonstrate suspected AS findings on PC-MRI and/or 3D-CISS sequences.

The contribution of 3D-CISS and contrast-enhanced MR cisternography in detecting cerebrospinal fluid leak in patients with rhinorrhoea

The aim of this prospective study was to evaluate the value of unenhanced (three-dimensional constructive interference in steady state (3D-CISS)) and contrast-enhanced MR cisternography (CE-MRC) in detecting the localisation of cerebrospinal fluid (CSF) leak in patients with rhinorrhoea. 17 patients with active or suspected CSF rhinorrhoea were included in the study. 3D-CISS sequences in coronal and sagittal planes and fat-suppressed T1-weighted spin-echo sequences in three planes before and after intrathecal contrast media administration were obtained. Images were obtained of the cribriform plate and sphenoid sinus. In addition, high-resolution CT (HRCT) was performed in order to evaluate the bony elements. The leak was present in 9/17 patients with 3D-CISS and 10/17 patients with CE-MRC. The leak from the cribriform plate to the nasal cavity in six patients and from the sphenoid sinus in four patients was nicely shown by CE-MRC. Eight of those patients were surgically treated, but spontaneous regression of the symptoms in two precluded any intervention. The leak localisations shown with CE-MRC were fully compatible with surgical results. The sensitivities of HRCT, 3D-CISS and CE-MRC for showing CSF leakage were 88%, 76% and 100%, respectively. In conclusion, 3D-CISS is a non-invasive and reliable technique, and should be the first-choice method to localise CSF leak. CE-MRC is helpful in conditions when there is no leak or in complicated cases with a positive beta2-transferrin measurement.

Phase-contrast cine MRI versus MR cisternography on the evaluation of the communication between intraventricular arachnoid cysts and neighbouring cerebrospinal fluid spaces

INTRODUCTION

The objective of this study was to evaluate the role of phase-contrast cine magnetic resonance imaging (PC-MRI) in detecting possible communications between intraventricular arachnoid cysts (IV-ACs) and cerebrospinal fluid (CSF) spaces based on MR cisternography (MRC) comparison.

MATERIALS AND METHODS

Twenty-one patients with IV-AC were examined by PC-MRI and MRC. In order to determine the communication of IVAC with its neighbouring CSF spaces, PC-MRI was employed. The communication of IV-ACs with the ventricular system was examined on at least two anatomic planes. Precontrast images and PC-MRI were followed by the intrathecal administration of 0.5-1 ml gadopentetate dimeglumine. Early and delayed MRC were then carried out. Results of PC-MRI were compared with findings of MRC (McNemar's test).

RESULTS

In seven IV-ACs, no communication was detected by PC-MRI. In 14 IVACs, a pulsatile CSF flow into the IV-ACs was observed. All the IV-ACs, which have been determined as non-communicating (NC) on the PC-MRI, showed NC character on MRC as well. Six cases suggesting a communication on PC-MRI showed no communication on MRC. MRC revealed eight communicating (38%) and 13 NC (62%) IV-ACs among a total of 21 cases. The sensitivity and specificity of PC-MRI imaging in demonstrating the communication between the IV-ACs and the CSF were 100% and 54%, respectively.

CONCLUSION

PC-MRI is an effective method for evaluating NC IV-ACs. In order to decide about the management of IV-ACs, which are communicating according to the PC-MRI, the results should be confirmed with MRC if suspected jet flow is depicted.