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

German chest pain unit registry: data review after the first decade of certification

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.

Nationwide but still inhomogeneous distribution of certified chest pain units across Germany : Need to strengthen rural regions

AIM

The purpose of this work was to analyze structure, distribution, and bed capacities of certified German chest pain units (CPUs) to unveil potential gaps despite nationwide certification of 230 units till the end of 2015.

METHODS

Analysis of number and structure of CPUs per state, resident count, and population density by standardized telephone interview, online research, and data collection from the registry of the Federal Statistical Office for all certified German CPUs.

RESULTS

Nationwide, German health facilities provided a mean of 1 CPU bed within a certified unit per 65,000 inhabitants. Bremen, Hamburg, Hesse, and Rhineland-Palatinate provided more than 1 bed per 50,000 inhabitants. Most CPUs (49%) were located in the emergency room. All university hospitals in Germany provided a certified CPU. Most units were found in academic teaching hospitals (146 CPUs). Only 42 CPUs were found in nonacademic providers of primary health care.

CONCLUSION

The absolute necessary number of CPUs to reach full nationwide coverage is still unknown. The current analysis shows a high number of CPUs and bed capacities within the cities and industrial areas without relevant gaps, but also demonstrates a certain undersupply in more rural areas as well as in some of the former eastern federal states of Germany.

First Update of the Criteria for Certification of Chest Pain Units in Germany: Facelift or New Model?

OBJECTIVE

In an effort to provide a systematic and specific standard-of-care for patients with acute chest pain, the German Cardiac Society introduced criteria for certification of specialized chest pain units (CPUs) in 2008, which have been replaced by a recent update published in 2015.

METHODS

We reviewed the development of CPU establishment in Germany during the past 7 years and compared and commented the current update of the certification criteria.

RESULTS

As of October 2015, 228 CPUs in Germany have been successfully certified by the German Cardiac Society; 300 CPUs are needed for full coverage closing gaps in rural regions. Current changes of the criteria mainly affect guideline-adherent adaptions of diagnostic work-ups, therapeutic strategies, risk stratification, in-hospital timing and education, and quality measures, whereas the overall structure remained unchanged. Benchmarking by participation within the German CPU registry is encouraged.

CONCLUSION

Even though the history is short, the concept of certified CPUs in Germany is accepted and successful underlined by its recent implementation in national and international guidelines. First registry data demonstrated a high standard of quality-of-care. The current update provides rational adaptions to new guidelines and developments without raising the level for successful certifications. A periodic release of fast-track updates with shorter time frames and an increase of minimum requirements should be considered.

Cardiac Computed Tomography in Certified German Chest Pain Units

OBJECTIVE

The German Cardiac Society runs a nation-wide certification campaign for specialized chest pain units (CPUs). So far, cardiac computed tomography (CT) is not an integral part of such certification. The aim of our study was to analyze whether or not cardiac CT is nevertheless routinely used for further stratification in low-risk patients.

METHODS

For the time interval from January 2010 to April 2011, data were retrieved from the mandatory German CPU registry. Patients with and without cardiac CT during CPU index stay were compared.

RESULTS

Out of 5800 patients, 314 patients (5.4%) underwent cardiac CT during the index CPU stay. Unstable angina pectoris was the most common diagnosis when performing cardiac CT [34.4% vs. 17.7%; odds ratio (OR), 2.44; confidence interval (CI), 1.91-3.11; P < 0.001). Patients undergoing cardiac CT received significantly less often coronary angiography (31.8% vs. 54.8%; OR, 0.39; CI, 0.30-0.49; P < 0.001) or coronary revascularization (15.6% vs. 36.5%; OR, 0.32; CI, 0.23-0.46; P < 0.001). The use of cardiac CT did not prolong the length of stay in the CPU (20:48 vs. 20:25 h, P = 0.21).

CONCLUSIONS

Cardiac CT is underrepresented within the diagnostic work up in certified CPUs in Germany, although its use reduces unnecessary invasive diagnostics. The use of cardiac CT should be reconsidered during the next update of the CPU certification criteria.

On- versus off-hour care for patients with non-ST-segment elevation myocardial infarction in Germany : Exemplary results within the chest pain unit concept

AIM

The aim of this study was to analyze differences in the timing of invasive management of patients with high-risk acute coronary syndrome without persistent ST-segment elevation (hr-NSTE-ACS) or myocardial infarction without persistent ST-segment elevation (NSTEMI) between on- and off-hours in a German chest pain unit (CPU).

PATIENTS AND METHODS

We retrospectively enrolled 160 NSTEMI patients in the study, who were admitted to two German CPUs in 2013. Patients presenting on weekdays between 8 a.m. and 6 p.m. were compared with patients presenting during off-hours. Data analysis included time intervals from admission to invasive management (goals: for hr-NSTE-ACS, <2 h; for NSTEMI, <24 h) and the resulting guideline adherence.

RESULTS

Guideline-adherent timing of an invasive strategy did not differ significantly between the on-hour (6.5 h [3.0-22.0 h], 79.9 %) and off-hour groups (10.5 h [2.0-20.0 h], 75.3 %; p = 0.94), without additional significant differences between admissions during off-hours Monday to Thursday and weekends (10.0 h [2.0-19.0 h], 75.6 % vs. 7.5 h [2.0-20.0 h], 76.2 %; p = 0.96).

CONCLUSION

Our exemplary experience in two different German CPUs demonstrates adequate timing of coronary catheterization in over 75 % of cases, irrespective of admission during on- or off-hours. Nationwide validation of our findings by the German CPU registry is mandatory.

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

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.

The Use of Echocardiography in Certified Chest Pain Units: Results from the German Chest Pain Unit Registry

OBJECTIVES

To analyze the current usage of transthoracic echocardiography (TTE) as a rapid, noninvasive tool in the early stratification of acute chest pain in certified German chest pain units (CPUs).

METHODS

A total of 23,997 patients were enrolled. Analyses comprised TTE evaluation rates in relation to clinical presentation, risk profile, left ventricular impairment, final diagnosis and invasive management. Critical times were assessed. Multivariable analyses for independent determinants for the use of TTE were performed.

RESULTS

TTE evaluation was available in CPUs in 70.1% of cases. It was associated with lower rates of invasive management in unstable angina pectoris (UAP) and with higher rates in patients with initially suspected non-cardiac origin of symptoms and/or reduced systolic function (p < 0.05). Non-ST-segment elevation acute coronary syndrome (NSTE-ACS) was an independent determinant favoring TTE evaluation [NSTE-myocardial infarction: odds ratio (OR) 1.62; UAP: OR 1.34; p < 0.001 for both]. Clinical signs of heart failure (OR 1.31; p < 0.001), referral by emergency medical service (OR 1.18; p < 0.001) and kidney failure (OR 1.16; p < 0.05) were independently associated with higher TTE rates. TTE did not delay door-to-balloon times.

CONCLUSIONS

About two thirds of the patients admitted to certified CPUs received TTE evaluation, with the highest rates being in ACS patients, and thereby providing diagnostic information supporting or refuting further invasive management.

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

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.

Anti-glioma action of aloe emodin: the role of ERK inhibition

The effect of aloe emodin (AE), a herbal anthraquinone derivative, on the rat C6 glioma cell line was investigated. In addition to cell cycle block and caspasedependent apoptosis, AE led to the formation of intracytoplasmic acidic vesicles indicative for autophagic cell death. Moreover, differentiation of surviving cells toward the astrocytic lineage was confirmed by typical morphological changes and increased expression of glial fibrillary acidic protein (GFAP). AE did not affect the activation of mitogen-activated protein kinase p38, Jun-N-terminal kinase, or transcription factor NF-kappaB, but markedly inhibited the activation of extracellular signal-regulated kinases 1 and 2 (ERK1/2) in C6 cells. A selective inhibitor of ERK activation, PD98059, mimicked the effects of AE on glioma cell morphology and GFAP expression, but failed to induce either apoptosis or autophagy. Taken together, these results indicate that the anti-glioma action of AE involves ERK-independent induction of both apoptosis and autophagy, as well as ERK inhibition-mediated differentiation of glioma cells.