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Eriksson-Liebon M, Westas M, Johansson P, Mourad G. Long-term effects and predictors of change of internet-delivered cognitive behavioural therapy on cardiac anxiety in patients with non-cardiac chest pain: a randomized controlled trial. BMC Psychiatry 2024; 24:216. [PMID: 38504157 PMCID: PMC10953164 DOI: 10.1186/s12888-024-05661-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 03/05/2024] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND Approximately half of patients who seek care at Emergency Departments due to chest pain are diagnosed with Non-Cardiac Chest Pain (NCCP). Concerns for heart disease and misinterpretation of the symptoms increase cardiac anxiety and have a negative impact on patients' lives. Psychological interventions such as internet-delivered cognitive behavioral therapy (iCBT) are effective in treating psychological conditions such as anxiety, by helping patients to learn how to manage chest pain. AIMS To evaluate the effects of a nurse-led iCBT program on cardiac anxiety and secondary outcomes, as bodily sensations, depressive symptoms, health-related quality of life and chest pain frequency in patients with NCCP at 6- and 12-month follow-up, and to explore predictors that can have impact on the effects of the iCBT program on psychological distress. METHODS A longitudinal study of a Randomized Controlled Trial (RCT) evaluating the long-term effects of an iCBT program (n = 54) in patients with NCCP, compared to psychoeducation (n = 55). The primary outcome, cardiac anxiety was measured using the Cardiac Anxiety Questionnaire (CAQ), and the secondary outcomes were measured with The Body Sensations Questionnaire (BSQ), Patient Health Questionnaire-9 (PHQ-9), The EuroQol Visual Analog Scale (EQ-VAS) and a self-developed question to measure chest pain frequency. All measurements were performed before and after the intervention, and 3, 6 and 12 months after the intervention. Linear mixed model was used to test between-group differences in primary and secondary outcomes and multiple regression analysis was used to explore factors that may have an impact on the treatment effect of iCBT on cardiac anxiety. RESULTS A total of 85% (n = 93/109) participants completed the 12-month follow-up. Mixed model analysis showed no statistically significant interaction effect of time and group between the iCBT and psychoeducation groups regarding cardiac anxiety over the 12-month follow-up. However, there was a statistically significant interaction effect of time and group (p = .009) regarding chest pain frequency favouring the iCBT group. In addition, we found a group effect in health-related quality of life (p = .03) favouring the iCBT group. The regression analysis showed that higher avoidance scores at baseline were associated with improvement in cardiac anxiety at 12-month follow-up. CONCLUSIONS Cardiac anxiety was reduced in patients with NCCP, but iCBT was not more effective than psychoeducation. Patients with a high tendency to avoid activities or situations that they believe could trigger cardiac symptoms may benefit more from psychological interventions targeting cardiac anxiety. TRIAL REGISTRATION The trial was registered at ClinicalTrials.gov NCT03336112 on 08/11/2017.
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Affiliation(s)
- Magda Eriksson-Liebon
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.
- Department of Emergency Medicine in Norrköping, and, Department of Biomedical and Clinical Sciences, Linköping University, Norrköping, Sweden.
| | - Mats Westas
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Peter Johansson
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Department of Internal Medicine in Norrköping, and, Department of Health, Medicine and Caring Sciences, Linköping University, Norrköping, Sweden
| | - Ghassan Mourad
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
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Spek M, Venekamp RP, Erkelens DCA, van Smeden M, Wouters LTCM, den Ruijter HM, Rutten FH, Zwart DL. Shortness of breath as a diagnostic factor for acute coronary syndrome in male and female callers to out-of-hours primary care. Heart 2024; 110:425-431. [PMID: 37827560 DOI: 10.1136/heartjnl-2023-323220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 09/23/2023] [Indexed: 10/14/2023] Open
Abstract
OBJECTIVE Chest discomfort and shortness of breath (SOB) are key symptoms in patients with acute coronary syndrome (ACS). It is, however, unknown whether SOB is valuable for recognising ACS during telephone triage in the out-of-hours primary care (OHS-PC) setting. METHODS A cross-sectional study performed in the Netherlands. Telephone triage conversations were analysed of callers with chest discomfort who contacted the OHS-PC between 2014 and 2017, comparing patients with SOB with those who did not report SOB. We determine the relation between SOB and (1) High urgency allocation, (2) ACS and (3) ACS or other life-threatening diseases. RESULTS Of the 2195 callers with chest discomfort, 1096 (49.9%) reported SOB (43.7% men, 56.3% women). In total, 15.3% men (13.2% in those with SOB) and 8.4% women (9.2% in those with SOB) appeared to have ACS. SOB compared with no SOB was associated with high urgency allocation (75.9% vs 60.8%, OR: 2.03; 95% CI 1.69 to 2.44, multivariable OR (mOR): 2.03; 95% CI 1.69 to 2.44), but not with ACS (10.9% vs 12.0%; OR: 0.90; 95% CI 0.69 to 1.17, mOR: 0.91; 95% CI 0.70 to 1.19) or 'ACS or other life-threatening diseases' (15.0% vs 14.1%; OR: 1.07; 95% CI 0.85 to 1.36, mOR: 1.09; 95% CI 0.86 to 1.38). For women the relation with ACS was 9.2% vs 7.5%, OR: 1.25; 95% CI 0.83 to 1.88, and for men 13.2% vs 17.4%, OR: 0.72; 95% CI 0.51 to 1.02. For 'ACS or other life-threatening diseases', this was 13.0% vs 8.5%, OR: 1.60; 95% CI 1.10 to 2.32 for women, and 7.5% vs 20.8%, OR: 0.81; 95% CI 0.59 to 1.12 for men. CONCLUSIONS Men and women with chest discomfort and SOB who contact the OHS-PC more often receive high urgency than those without SOB. This seems to be adequate in women, but not in men when considering the risk of ACS or other life-threatening diseases.
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Affiliation(s)
- Michelle Spek
- Department of General Practice and Nursing Science, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Roderick P Venekamp
- Department of General Practice and Nursing Science, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Daphne C A Erkelens
- Department of General Practice and Nursing Science, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Maarten van Smeden
- Department of Epidemiology, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Loes T C M Wouters
- Department of General Practice and Nursing Science, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Hester M den Ruijter
- Laboratory of Experimental Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Frans H Rutten
- Department of General Practice and Nursing Science, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Dorien L Zwart
- Department of General Practice and Nursing Science, Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht, The Netherlands
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Khand A, Brankin-Frisby T, Gornall M, Hatherley J, Raj R, Campbell M, Salmon T, Yang YH, Grainger R. Independent Predictors of Repeat Emergency Room Presentations: Insights from a Cohort of 1066 Consecutive Patients with Non-Cardiac Chest Pain Generating 4770 Repeat Presentations. J Clin Med 2023; 12:5290. [PMID: 37629331 PMCID: PMC10455527 DOI: 10.3390/jcm12165290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 07/08/2023] [Accepted: 07/19/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND AND IMPORTANCE Chest pain (CP) is one of the most frequent presentations to the emergency department (ED), a large proportion of which is non-cardiac chest pain (NCCP). Repeat attendances to ED are common and impose considerable burden to overstretched departments. OBJECTIVE Our aim was to determine drivers for repeat ED presentations using NCCP as the primary cause of index presentation. DESIGN, SETTING AND PARTICIPANTS This was a retrospective cohort study of 1066 consecutive presentations with NCCP to a major urban hospital ED in North England. Index of Multiple Deprivation (IMD), a postcode-derived validated index of deprivation, was computed. Charlson comorbidity index (CCI) was determined by reference to known comorbidity variables. Repeat presentation to ED to any national hospital was determined by a national linked database (population 53.5 million). Independent predictors of ED representation were computed using logistic regression analysis. RESULTS Median age was 43 (IQR 28-59), and 50.8% were male. Furthermore, 27.8%, 8.1% and 3.8% suffered from chronic obstructive pulmonary disease (COPD), hypertension and diabetes mellitus, respectively. The most frequent diagnoses, using ICD-10 coding, were non-cardiac chest pain (55.1%), followed by respiratory conditions (14.7%). One-year incidence of adjudicated myocardial infarction, urgent or emergency coronary revascularisation and all-cause death was 0.6%, 2% and 5.3%, respectively. There was a total of 4770 ED repeat presentations 1 year prior to or following index presentation with NCCP in this cohort. Independent (multivariate) predictors for frequent re-presentation (defined as ≥2 representations) were a history of COPD (OR [odds ratio] 2.06, p = 0.001), previous MI (OR3.6, p = 0.020) and a Charlson comorbidity index ≥1 (OR 1.51, p = 0.030). The frequency of previous MI was low as only 3% had sustained a previous MI. CONCLUSIONS This analysis indicates that COPD and complex health care needs (represented by high CCI), but not socio-economic deprivation, should be health policy targets for lessening repeat ED presentations. What is already known on this topic: Repeat presentations with non-ischaemic chest pain are common, placing a considerable burden on emergency departments. WHAT THIS STUDY ADDS COPD and complex health care needs, denoted by Charlson comorbidity index, are implicated as drivers for repeat presentation to accident and emergency department. Socio-economic deprivation was not an independent predictor of re-presentation. How might this study affect research, practice, or policy: Community-based support for COPD and complex health care needs may reduce frequency of ED attendance.
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Affiliation(s)
- Aleem Khand
- Liverpool University Hospitals NHS Foundation Trust, Liverpool L9 7AL, UK (T.S.); (Y.-h.Y.)
- Liverpool Heart and Chest Hospital, Liverpool L14 3PE, UK
- Department of Ageing and Chronic Diseases, University of Liverpool, Liverpool L69 3BX, UK
| | - Thomas Brankin-Frisby
- Liverpool University Hospitals NHS Foundation Trust, Liverpool L9 7AL, UK (T.S.); (Y.-h.Y.)
| | - Matthew Gornall
- Clinical Trials Unit, University of Liverpool, Liverpool L69 3BX, UK
| | - James Hatherley
- Liverpool University Hospitals NHS Foundation Trust, Liverpool L9 7AL, UK (T.S.); (Y.-h.Y.)
| | - Ray Raj
- Liverpool University Hospitals NHS Foundation Trust, Liverpool L9 7AL, UK (T.S.); (Y.-h.Y.)
| | - Michael Campbell
- Liverpool University Hospitals NHS Foundation Trust, Liverpool L9 7AL, UK (T.S.); (Y.-h.Y.)
| | - Thomas Salmon
- Liverpool University Hospitals NHS Foundation Trust, Liverpool L9 7AL, UK (T.S.); (Y.-h.Y.)
| | - Yi-han Yang
- Liverpool University Hospitals NHS Foundation Trust, Liverpool L9 7AL, UK (T.S.); (Y.-h.Y.)
| | - Ruth Grainger
- North-West Coast Academic Science Network, Cheshire WA4 4AB, UK
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Maeno K, Satoh K, Hirasawa N, Okuyama M, Nakae H. Chest Pain Diagnosed as Acute Leukemia: Focus on Coagulation Abnormalities Rather Than White Blood Cell Count. Cureus 2023; 15:e35992. [PMID: 37041914 PMCID: PMC10083076 DOI: 10.7759/cureus.35992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2023] [Indexed: 03/12/2023] Open
Abstract
Chest pain is an important symptom for emergency physicians. It is one of the most common causes for admission in emergency departments. Acute leukemia (AL) rarely causes chest symptoms due to ostalgia, and it is difficult to diagnose leukemia as the cause of chest pain. An 83-year-old woman with no history of trauma presented to the emergency department with a one-day history of severe chest pain. There were no abnormalities on electrocardiography, echocardiography, specific biomarkers for cardiac injury, or contrast computed tomography of the chest and pelvis. The white blood cell count was normal, but the patient had prominent thrombocytopenia with platelets of 68,000/µL, prothrombin time-international normalized ratio (PT-INR) of 1.2, activated partial thromboplastin time (APTT) of 25.3 s, and D-dimer of 73.55 µg/mL. Due to the holiday, blast cells could not be measured on the same day. The next day's examination revealed blast cells in the peripheral blood. The patient was admitted to the hematology department and discharged three months later. This case suggests the need to consider AL in chest pain associated with coagulation abnormalities and thrombocytopenia, regardless of the white blood cell count.
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Wouters LTCM, Zwart DLM, Erkelens DCA, Adriaansen EJM, den Ruijter HM, De Groot E, Damoiseaux RAMJ, Hoes AW, van Smeden M, Rutten FH. Development and validation of a prediction rule for patients suspected of acute coronary syndrome in primary care: a cross-sectional study. BMJ Open 2022; 12:e064402. [PMID: 36198462 PMCID: PMC9535154 DOI: 10.1136/bmjopen-2022-064402] [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] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE To develop and validate a symptom-based prediction rule for early recognition of acute coronary syndrome (ACS) in patients with acute chest discomfort who call out-of-hours services for primary care (OHS-PC). DESIGN Cross-sectional study. A diagnostic prediction rule was developed with multivariable regression analyses. All models were validated with internal-external cross validation within seven OHS-PC locations. Both age and sex were analysed as statistical interaction terms, applying for age non-linear effects. SETTING Seven OHS-PC in the Netherlands. PARTICIPANTS 2192 patients who called OHS-PC for acute chest discomfort (pain, pressure, tightness or discomfort) between 2014 and 2017. Backed up recordings of telephone triage conversations were analysed. PRIMARY AND SECONDARY OUTCOMES MEASURES Diagnosis of ACS retrieved from the patient's medical records in general practice, including hospital specialists discharge letters. Performance of the prediction rules was calculated with the c-statistic and the final model was chosen based on net benefit analyses. RESULTS Among the 2192 patients who called the OHS-PC with acute chest discomfort, 8.3% females and 15.3% males had an ACS. The final diagnostic model included seven predictors (sex, age, acute onset of chest pain lasting less than 12 hours, a pressing/heavy character of the pain, radiation of the pain, sweating and calling at night). It had an adjusted c-statistic of 0.77 (95% CI 0.74 to 0.79) with good calibration. CONCLUSION The final prediction model for ACS has good discrimination and calibration and shows promise for replacing the existing telephone triage rules for patients with acute chest discomfort in general practice and OHS-PC. TRIAL REGISTRATION NUMBER NTR7331.
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Affiliation(s)
- Loes T C M Wouters
- Department of General Practice, Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands
| | - Dorien L M Zwart
- Department of General Practice, Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands
| | - Daphne C A Erkelens
- Department of General Practice, Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands
| | - Elisabeth J M Adriaansen
- Department of General Practice, Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands
| | - Hester M den Ruijter
- Department of Experimental Cardiology, Utrecht University, Utrecht, The Netherlands
| | - Esther De Groot
- Julius Center for Health Sciences and Primary Care, Utrecht University, Utrecht, The Netherlands
| | - Roger A M J Damoiseaux
- Department of General Practice, Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands
| | - Arno W Hoes
- Department of General Practice, Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands
| | - Maarten van Smeden
- Department of Methodology, Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands
| | - Frans H Rutten
- Department of General Practice, Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands
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Saeed N, Norekvål TM, Steiro OT, Tjora HL, Langørgen J, Bjørneklett RO, Skadberg Ø, Bonarjee VVS, Mjelva ØR, Omland T, Vikenes K, Aakre KM. Predictors of long-term symptom burden and quality of life in patients hospitalised with chest pain: a prospective observational study. BMJ Open 2022; 12:e062302. [PMID: 35831040 PMCID: PMC9280876 DOI: 10.1136/bmjopen-2022-062302] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE To describe the magnitude and predictors of symptom burden (SB) and quality of life (QoL) 3 months after hospital admission for acute chest pain. DESIGN Prospective observational study. SETTING Single centre, outpatient follow-up. PARTICIPANTS 1506 patients. OUTCOMES Scores reported for general health (RAND-12), angina-related health (Seattle Angina Questionnaire 7 (SAQ-7)) and dyspnoea (Rose Dyspnea Scale) 3 months after hospital admission for chest pain. METHODS A total of 1506 patients received questionnaires assessing general health (RAND-12), angina-related health (SAQ-7) and dyspnoea (Rose Dyspnea Scale) 3 months after discharge. Univariable and multivariable regression models identified predictors of SB and QoL scores. A mediator analysis identified factors mediating the effect of an unstable angina pectoris (UAP) diagnosis. RESULTS 774 (52%) responded. Discharge diagnoses were non-ST elevation myocardial infarction (NSTEMI) (14.2%), UAP (17.1%), non-coronary cardiac disease (6.6%), non-cardiac disease (6.3%) and non-cardiac chest pain (NCCP) (55.6%). NSTEMI had the most favourable, and UAP patients the least favourable SAQ-7 scores (median SAQ7-summary; 88 vs 75, p<0.001). NCCP patients reported persisting chest pain in 50% and dyspnoea in 33% of cases. After adjusting for confounders, revascularisation predicted better QoL scores, while UAP, current smoking and hypertension predicted worse outcome. NSTEMI and UAP patients who were revascularised reported higher scores (p<0.05) in SAQ-7-QL, SAQ7-PL, SAQ7-summary (NSTEMI) and all SAQ-7 domains (UAP). Revascularisation altered the unstandardised beta value (>±10%) of an UAP diagnosis for all SAQ-7 and RAND-12 outcomes. CONCLUSIONS Patients with NSTEMI reported the most favourable outcome 3 months after hospitalisation for chest pain. Patients with other diseases, in particular UAP patients, reported lower scores. Revascularised NSTEMI and UAP patients reported higher QoL scores compared with patients receiving conservative treatment. Revascularisation mediated all outcomes in UAP patients. TRIAL REGISTRATION NUMBER NCT02620202.
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Affiliation(s)
- Nasir Saeed
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Tone Merete Norekvål
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Ole-Thomas Steiro
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Hilde Lunde Tjora
- Emergency Care Clinic, Haukeland University Hospital, Bergen, Norway
| | - Jørund Langørgen
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Rune Oskar Bjørneklett
- Emergency Care Clinic, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Øyvind Skadberg
- Laboratory of Medical Biochemistry, Stavanger University Hospital, Stavanger, Norway
| | | | | | - Torbjørn Omland
- Institute for Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Cardiology, Akershus University Hospital, Oslo, Norway
| | - Kjell Vikenes
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
| | - Kristin Moberg Aakre
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Heart Disease, Haukeland University Hospital, Bergen, Norway
- Department of Medical Biochemistry and Pharmacology, Haukeland University Hospital, Bergen, Norway
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Rountree LM, Mirzaei S, Brecht ML, Rosenfeld AG, Daya MR, Knight DNP E, Zègre-Hemsey JK, Frisch S, Dunn SL, Birchfield J, DeVon HA. There is little association between prehospital delay, persistent symptoms, and post-discharge healthcare utilization in patients evaluated for acute coronary syndrome. Appl Nurs Res 2022; 65:151588. [PMID: 35577486 PMCID: PMC9841768 DOI: 10.1016/j.apnr.2022.151588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 03/27/2022] [Accepted: 04/28/2022] [Indexed: 01/18/2023]
Abstract
AIMS Test for an association between prehospital delay for symptoms suggestive of acute coronary syndrome (ACS), persistent symptoms, and healthcare utilization (HCU) 30-days and 6-months post hospital discharge. BACKGROUND Delayed treatment for ACS increases patient morbidity and mortality. Prehospital delay is the largest factor in delayed treatment for ACS. METHODS Secondary analysis of data collected from a multi-center prospective study. Included were 722 patients presenting to the Emergency Department (ED) with symptoms that triggered a cardiac evaluation. Symptoms and HCU were measured using the 13-item ACS Symptom Checklist and the Froelicher's Health Services Utilization Questionnaire-Revised instrument. Logistic regression models were used to examine hypothesized associations. RESULTS For patients with ACS (n = 325), longer prehospital delay was associated with fewer MD/NP visits (OR, 0.986) at 30 days. Longer prehospital delay was associated with higher odds of calling 911 for any reason (OR, 1.015), and calling 911 for chest related symptoms (OR, 1.016) 6 months following discharge. For non-ACS patients (n = 397), longer prehospital delay was associated with higher odds of experiencing chest pressure (OR, 1.009) and chest discomfort (OR, 1.008) at 30 days. At 6 months, longer prehospital delay was associated with higher odds of upper back pain (OR, 1.013), palpitations (OR 1.014), indigestion (OR, 1.010), and calls to the MD/NP for chest symptoms (OR, 1.014). CONCLUSIONS There were few associations between prehospital delay and HCU for patients evaluated for ACS in the ED. Associations between prolonged delay and persistent symptoms may lead to increased HCU for those without ACS.
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Affiliation(s)
- Lauren M. Rountree
- University of California, Los Angeles, Factor Bldg., 700 Tiverton Dr, Los Angeles, CA 90095
| | - Sahereh Mirzaei
- University of California, Los Angeles, Factor Bldg., 700 Tiverton Dr, Los Angeles, CA 90095
| | - Mary-Lynn Brecht
- University of California, Los Angeles, Factor Bldg., 700 Tiverton Dr, Los Angeles, CA 90095
| | - Anne G. Rosenfeld
- University of Arizona, College of Nursing, 1305 N Martin Ave, Tucson, AZ 85721
| | - Mohamud R. Daya
- Oregon Health & Science University, School of Nursing, 3455 SW US Veterans Hospital Rd, Portland, OR 97239
| | - Elizabeth Knight DNP
- Oregon Health & Science University, School of Nursing, 3455 SW US Veterans Hospital Rd, Portland, OR 97239
| | - Jessica K. Zègre-Hemsey
- University of North Carolina, School of Nursing, Carrington Hall, S Columbia St, Chapel Hill, NC 27599
| | - Stephanie Frisch
- University of Pittsburgh, School of Nursing, 3500 Victoria St, Pittsburgh, PA 15213
| | - Susan L. Dunn
- University of Illinois Chicago, College of Nursing, 845 S Damen Ave, Chicago, IL 60612
| | - Jesse Birchfield
- University of California, Los Angeles, Factor Bldg., 700 Tiverton Dr, Los Angeles, CA 90095
| | - Holli A. DeVon
- University of California, Los Angeles, Factor Bldg., 700 Tiverton Dr, Los Angeles, CA 90095
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Ballantyne JC, Sullivan MD. Is Chronic Pain a Disease? THE JOURNAL OF PAIN 2022; 23:1651-1665. [PMID: 35577236 DOI: 10.1016/j.jpain.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 04/24/2022] [Accepted: 05/06/2022] [Indexed: 11/30/2022]
Abstract
It was not until the twentieth century that pain was considered a disease. Before that it was managed medically as a symptom. The motivations for declaring chronic pain a disease, whether of the body or of the brain, include increasing its legitimacy as clinical problem and research focus worthy of attention from healthcare and research organizations alike. But 1 problem with disease concepts is that having a disease favors medical solutions and tends to reduce patient participation. We argue that chronic pain, particularly chronic primary pain (recently designated a first tier pain diagnosis in International Diagnostic Codes 11), is a learned state that is not intransigent even if it has biological correlates. Chronic pain is sometimes a symptom, and may sometimes be its own disease. But here we question the value of a disease focus for much of chronic pain for which patient involvement is essential, and which may need a much broader societal approach than is suggested by the disease designation. PERSPECTIVE: This article examines whether designating chronic pain a disease of the body or brain is helpful or harmful to patients. Can the disease designation help advance treatment, and is it needed to achieve future therapeutic breakthrough? Or does it make patients over-reliant on medical intervention and reduce their engagement in the process of recovery?
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Affiliation(s)
- Jane C Ballantyne
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, Washington.
| | - Mark D Sullivan
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington
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Henningsen P, Laugwitz KL. [Functional cardiovascular symptoms]. Dtsch Med Wochenschr 2022; 147:604-612. [PMID: 35545069 DOI: 10.1055/a-1554-1706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
This review provides an update on the diagnosis, differential diagnosis and management of functional cardiovascular symptoms. Typical heart-related symptoms like non-cardiac chest pain and palpitations are frequently complemented by other symptoms like dyspnea, sweating, trembling, dizziness and also further somatic symptoms like pain and fatigue. Functional cardiac symptoms are frequent, with rates of up to 30 % in chest pain units. The differential diagnosis comprises gastrointestinal disorders like gastro-esophageal reflux disease and also mental disorders, particularly panic and other anxiety disorders. Successful management depends on an attitude of realizing and confirming the reality and seriousness of the symptoms despite the absence of a clear structural organic cause. Good cooperation with psychotherapists is helpful for stepped care strategies that start with supportive communication with the patient and biopsychosocial self-help activities, leading, if necessary, to formal psychotherapy.
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Mourad G, Eriksson-Liebon M, Karlström P, Johansson P. The Effect of Internet-Delivered Cognitive Behavioral Therapy Versus Psychoeducation Only on Psychological Distress in Patients With Noncardiac Chest Pain: Randomized Controlled Trial. J Med Internet Res 2022; 24:e31674. [PMID: 35089153 PMCID: PMC8838599 DOI: 10.2196/31674] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 11/09/2021] [Accepted: 12/08/2021] [Indexed: 01/19/2023] Open
Abstract
Background Patients with recurrent episodes of noncardiac chest pain (NCCP) experience cardiac anxiety as they misinterpret the pain to be cardiac related and avoid physical activity that they think could threaten their lives. Psychological interventions, such as internet-delivered cognitive behavioral therapy (iCBT), targeting anxiety can be a feasible solution by supporting patients to learn how to perceive and handle their chest pain. Objective This study aims to evaluate the effects of a nurse-led iCBT program on cardiac anxiety and other patient-reported outcomes in patients with NCCP. Methods Patients with at least two health care consultations because of NCCP during the past 6 months, and who were experiencing cardiac anxiety (Cardiac Anxiety Questionnaire score ≥24), were randomized into 5 weeks of iCBT (n=54) or psychoeducation (n=55). Patients were aged 54 (SD 17) years versus 57 (SD 16) years and were mainly women (32/54, 59% vs 35/55, 64%). The iCBT program comprised psychoeducation, mindfulness, and exposure to physical activity, with weekly homework assignments. The primary outcome was cardiac anxiety. The secondary outcomes were fear of bodily sensations, depressive symptoms, health-related quality of life, and chest pain frequency. Intention-to-treat analysis was applied, and the patients were followed up for 3 months. Mixed model analysis was used to determine between-group differences in primary and secondary outcomes. Results No significant differences were found between the iCBT and psychoeducation groups regarding cardiac anxiety or any of the secondary outcomes in terms of the interaction effect of time and group over the 3-month follow-up. iCBT demonstrated a small effect size on cardiac anxiety (Cohen d=0.31). In the iCBT group, 36% (16/44) of patients reported a positive reliable change score (≥11 points on the Cardiac Anxiety Questionnaire), and thus an improvement in cardiac anxiety, compared with 27% of (13/48) patients in the psychoeducation group. Within-group analysis showed further significant improvement in cardiac anxiety (P=.04) at the 3-month follow-up compared with the 5-week follow-up in the iCBT group but not in the psychoeducation group. Conclusions iCBT was not superior to psychoeducation in decreasing cardiac anxiety in patients with NCCP. However, iCBT tends to have better long-term effects on psychological distress, including cardiac anxiety, health-related quality of life, and NCCP frequency than psychoeducation. The effects need to be followed up to draw more reliable conclusions. Trial Registration ClinicalTrials.gov NCT03336112; https://www.clinicaltrials.gov/ct2/show/NCT03336112
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Affiliation(s)
- Ghassan Mourad
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Magda Eriksson-Liebon
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.,Department of Emergency Medicine in Norrköping, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Patric Karlström
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.,Department of Internal Medicine, Ryhov County Hospital, Region Jönköping County, Jönköping, Sweden
| | - Peter Johansson
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.,Department of Internal Medicine in Norrköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
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11
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Alotaibi A, Body R, Carley S, Pennington E. Towards enhanced telephone triage for chest pain: a Delphi study to define life-threatening conditions that must be identified. BMC Emerg Med 2021; 21:158. [PMID: 34911466 PMCID: PMC8672334 DOI: 10.1186/s12873-021-00553-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 12/01/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Improving telephone triage for patients with chest pain has been identified as a national research priority. However, there is a lack of strong evidence to define the life-threatening conditions (LTCs) that telephone triage ought to identify. Therefore, we aimed to build consensus for the LTCs associated with chest pain that ought to be identified during telephone triage for emergency calls. METHODS We conducted a Delphi study in three rounds. Twenty experts in pre-hospital care and emergency medicine experience from the UK were invited to participate. In round I, experts were asked to list all LTCs that would require priority 1, 2, and 4 ambulance responses. Round II was a ranking evaluation, and round III was a consensus round. Consensus level was predefined at > = 70%. RESULTS A total of 15 participants responded to round one and 10 to rounds two and three. Of 185 conditions initially identified by the experts, 26 reached consensus in the final round. Ten conditions met consensus for requiring priority 1 response: oesophageal perforation/rupture; ST elevation myocardial infarction; non-ST elevation myocardial infarction with clinical compromise (defined, also by consensus, as oxygen saturation < 90%, heart rate < 40/min or systolic blood pressure < 90 mmHg); acute heart failure; cardiac tamponade; life-threatening asthma; cardiac arrest; tension pneumothorax and massive pulmonary embolism. An additional six conditions met consensus for priority 2 response, and three for priority 4 response. CONCLUSION Using expert consensus, we have defined the LTCs that may present with chest pain, which ought to receive a high-priority ambulance response. This list of conditions can now form a composite primary outcome for future studies to derive and validate clinical prediction models that will optimise telephone triage for patients with a primary complaint of chest pain.
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Affiliation(s)
- Ahmed Alotaibi
- Division of Cardiovascular Sciences, Core Technology Facility, University of Manchester, 46 Grafton St, Manchester, M13 9WU, UK.
- College of Applied Medical Sciences, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.
| | - Richard Body
- Division of Cardiovascular Sciences, Core Technology Facility, University of Manchester, 46 Grafton St, Manchester, M13 9WU, UK
- Emergency Department, Manchester University NHS Foundation Trust, Manchester, UK
| | - Simon Carley
- Emergency Department, Manchester University NHS Foundation Trust, Manchester, UK
- Faculty of Health, Social Care & Psychology, Manchester Metropolitan University, Manchester, UK
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12
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Chen J, Wijesundara JG, Patterson A, Cutrona SL, Aiello S, McManus DD, McKee MD, Wang B, Houston TK. Facilitators and barriers to post-discharge pain assessment and triage: a qualitative study of nurses' and patients' perspectives. BMC Health Serv Res 2021; 21:1021. [PMID: 34583702 PMCID: PMC8480104 DOI: 10.1186/s12913-021-07031-w] [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: 04/24/2021] [Accepted: 09/11/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND After hospital discharge, patients can experience symptoms prompting them to seek acute medical attention. Early evaluation of patients' post-discharge symptoms by healthcare providers may improve appropriate healthcare utilization and patient safety. Post-discharge follow-up phone calls, which are used for routine transitional care in U.S. hospitals, serve as an important channel for provider-patient communication about symptoms. This study aimed to assess the facilitators and barriers to evaluating and triaging pain symptoms in cardiovascular patients through follow-up phone calls after their discharge from a large healthcare system in Central Massachusetts. We also discuss strategies that may help address the identified barriers. METHODS Guided by the Practical, Robust, Implementation and Sustainability Model (PRISM), we completed semi-structured interviews with 7 nurses and 16 patients in 2020. Selected nurses conducted (or supervised) post-discharge follow-up calls on behalf of 5 clinical teams (2 primary care; 3 cardiology). We used thematic analysis to identify themes from interviews and mapped them to the domains of the PRISM model. RESULTS Participants described common facilitators and barriers related to the four domains of PRISM: Intervention (I), Recipients (R), Implementation and Sustainability Infrastructure (ISI), and External Environment (EE). Facilitators include: (1) patients being willing to receive provider follow-up (R); (2) nurses experienced in symptom assessment (R); (3) good care coordination within individual clinical teams (R); (4) electronic health record system and call templates to support follow-up calls (ISI); and (5) national and institutional policies to support post-discharge follow-up (EE). Barriers include: (1) limitations of conducting symptom assessment by provider-initiated follow-up calls (I); (2) difficulty connecting patients and providers in a timely manner (R); (3) suboptimal coordination for transitional care among primary care and cardiology providers (R); and (4) lack of emphasis on post-discharge follow-up call reimbursement among cardiology clinics (EE). Specific barriers for pain assessment include: (1) concerns with pain medication misuse (R); and (2) no standardized pain assessment and triage protocol (ISI). CONCLUSIONS Strategies to empower patients, facilitate timely patient-provider communication, and support care coordination regarding pain evaluation and treatment may reduce the barriers and improve processes and outcomes of pain assessment and triage.
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Affiliation(s)
- Jinying Chen
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, 368 Plantation Street, Worcester, MA, 01605, USA.
| | - Jessica G Wijesundara
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, 368 Plantation Street, Worcester, MA, 01605, USA
| | - Angela Patterson
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, 368 Plantation Street, Worcester, MA, 01605, USA
| | - Sarah L Cutrona
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, 368 Plantation Street, Worcester, MA, 01605, USA
| | | | - David D McManus
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - M Diane McKee
- Department of Family Medicine and Community Health, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Bo Wang
- Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, 368 Plantation Street, Worcester, MA, 01605, USA
| | - Thomas K Houston
- Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, NC, USA
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13
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Wouters LTCM, Zwart DLM, Erkelens DCA, De Groot E, van Smeden M, Hoes AW, Damoiseaux RAMJ, Rutten FH. Gender-stratified analyses of symptoms associated with acute coronary syndrome in telephone triage: a cross-sectional study. BMJ Open 2021; 11:e042406. [PMID: 34172542 PMCID: PMC8237735 DOI: 10.1136/bmjopen-2020-042406] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVES To identify clinical variables that are associated with the diagnosis acute coronary syndrome (ACS) in women and men with chest discomfort who contact out-of-hours primary care (OHS-PC) by telephone, and to explore whether there are indications whether these variables differ among women and men. DESIGN Cross-sectional study in which we compared patient and call characteristics of triage call recordings between women with and without ACS, and men with and without ACS. SETTING Nine OHS-PC in the Netherlands. PARTICIPANTS 993 women and 802 men who called OHS-PC for acute chest discomfort (pain, pressure, tightness or discomfort) between 2014 and 2016. PRIMARY OUTCOME MEASURE Diagnosis of ACS retrieved from the patient's medical record in general practice, including hospital specialists' discharge letters. RESULTS Among 1795 patients (mean age 58.8 (SD 19.5) years, 55.3% women), 15.0% of men and 8.6% of women had an ACS. In both sexes, retrosternal chest pain was associated with ACS (women with ACS vs without 62.3% vs 40.3%, p=0.002; men with ACS vs without 52.5% vs 39.7%, p=0.032; gender interaction, p=0.323), as was pressing/heavy/tightening pain (women 78.6% vs 61.5%, p=0.011; men 82.1% vs 57.4%, p=<0.001; gender interaction, p=0.368) and radiation to the arm (women 75.6% vs 45.9%, p<0.001; men 56.0% vs 34.8%, p<0.001; gender interaction, p=0.339). Results indicate that only in women were severe pain (65.4% vs 38.1%, p=0.006; gender interaction p=0.007) and radiation to jaw (50.0% vs 22.9%, p=0.007; gender interaction p=0.015) associated with ACS.Ambulances were dispatched equally in women (72.9%) and men with ACS (70.0%). CONCLUSION Our results indicate there were more similarities than differences in symptoms associated with the diagnosis ACS for women and men. Important exceptions were pain severity and radiation of pain in women. Whether these differences have an impact on predicting ACS needs to be further investigated with multivariable analyses. TRIAL REGISTRATION NUMBER NTR7331.
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Affiliation(s)
- Loes T C M Wouters
- Julius Center for Health Sciences and Primary Care, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
| | - Dorien L M Zwart
- Julius Center for Health Sciences and Primary Care, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
| | - Daphne C A Erkelens
- Julius Center for Health Sciences and Primary Care, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
| | - Esther De Groot
- Julius Center for Health Sciences and Primary Care, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
| | - Maarten van Smeden
- Epidemiology, Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands
| | - Arno W Hoes
- Julius Center for Health Sciences and Primary Care, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
| | - Roger A M J Damoiseaux
- Julius Center for Health Sciences and Primary Care, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
| | - Frans H Rutten
- Julius Center for Health Sciences and Primary Care, Universitair Medisch Centrum Utrecht, Utrecht, The Netherlands
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14
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Rogers J, Collins G, Husain M, Docherty M. Identifying and managing functional cardiac symptoms. Clin Med (Lond) 2021; 21:37-43. [PMID: 33479066 DOI: 10.7861/clinmed.2020-0934] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Recurring chest pain and other cardiac symptoms that cannot be adequately explained by organic pathology are common and can be associated with substantial disability, distress and high healthcare costs. Common mental disorders such as depression and anxiety frequently co-occur with these symptoms and, in some cases, account for their presentation, although they are not universally present. Due to the frequency of functional cardiac presentations and risks of iatrogenic harm, physicians should be familiar with strategies to identify, assess and communicate with patients about these symptoms. A systematic and multidisciplinary approach to diagnosis and management is often needed. Health beliefs, concerns and any associated behaviours should be elicited and addressed throughout. Psychiatric comorbidities should be concurrently identified and treated. For those with persistent symptoms, psychosocial outcomes can be poor, highlighting the need for further research and investment in diagnostic and therapeutic approaches and multidisciplinary service models.
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Affiliation(s)
- Jonathan Rogers
- University College London, London, UK and specialty registrar in general adult and old age psychiatry, South London and Maudsley NHS Foundation Trust, London, UK
| | - George Collins
- University College London, London, UK and specialty registrar in cardiology, Barts Health NHS Trust, London, UK
| | - Mujtaba Husain
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Mary Docherty
- South London and Maudsley NHS Foundation Trust, London, UK
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15
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Wouters LT, Rutten FH, Erkelens DC, De Groot E, Damoiseaux RA, Zwart DL. Accuracy of telephone triage in primary care patients with chest discomfort: a cross-sectional study. Open Heart 2020; 7:openhrt-2020-001376. [PMID: 32958556 PMCID: PMC7507892 DOI: 10.1136/openhrt-2020-001376] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 07/06/2020] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To assess the accuracy of semi-automatic assisted telephone triage in patients with acute chest discomfort against the diagnosis of acute coronary syndrome (ACS) or other life-threatening events (LTEs). METHODS A cross-sectional study was performed of telephone conversations with 2023 patients with acute chest discomfort (pain, pressure, tightness or discomfort) who called out-of-hours services for primary care (OHS-PC) between 2014 and 2016. Sensitivity, specificity, positive and negative predicted values were calculated for a high urgency (patient seen within one hour) against the diagnoses of ACS and other LTEs. Diagnoses were retrieved from the patients' medical records in general practice, including hospital specialists' discharge letters. RESULTS Of 2023 patients who called because of chest discomfort, 227 (11.2%) had an ACS (men 14.9%, women 8.2%) and 58 (2.9%) had another LTE (men 3.6%, women 2.3%). The sensitivity and specificity of a high Netherlands Triage System (NTS) urgency allocation against ACS/other LTEs were 0.73 (95% CI 0.68 to 0.78) and 0.43 (95% CI 0.40 to 0.45), respectively. In 13.2% of the calls the triage nurse overruled the NTS urgency, mostly by upscaling (11.0%). The sensitivity and specificity of the final urgency allocation were 0.86 (95% CI 0.81 to 0.90) and 0.34 (95% CI 0.32 to 0.37). The positive and negative predictive values of the final urgency were 0.18 (95% CI 0.17 to 0.19) and 0.94 (95% CI 0.92 to 0.95), respectively. CONCLUSIONS The semi-automatic triage NTS tool underestimated the urgency in 27% of patients with ACS/other LTEs. Overruling by triage nurses improved safety, but still 14% of men and women with ACS/other LTEs received too low urgency, while efficiency remained poor. TRIAL REGISTRATION NUMBER NTR7331.
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Affiliation(s)
- Loes Tcm Wouters
- General Practice, Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands
| | - Frans H Rutten
- General Practice, Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands
| | - Daphne Ca Erkelens
- General Practice, Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands
| | - Esther De Groot
- General Practice, Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands
| | - Roger Amj Damoiseaux
- General Practice, Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands
| | - Dorien Lm Zwart
- General Practice, Julius Center for Health Sciences and Primary Care, Utrecht, The Netherlands
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16
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Wouters LT, Zwart DL, Erkelens DC, Cheung NS, de Groot E, Damoiseaux RA, Hoes AW, Rutten FH. Chest discomfort at night and risk of acute coronary syndrome: cross-sectional study of telephone conversations. Fam Pract 2020; 37:473-478. [PMID: 31996901 PMCID: PMC7474533 DOI: 10.1093/fampra/cmaa005] [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] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND During telephone triage, it is difficult to assign adequate urgency to patients with chest discomfort. Considering the time of calling could be helpful. OBJECTIVE To assess the risk of acute coronary syndrome (ACS) in certain time periods and whether sex influences this risk. METHODS Cross-sectional study of 1655 recordings of telephone conversations of patients who called the out-of-hours services primary care (OHS-PC) for chest discomfort. Call time, patient characteristics, symptoms, medical history and urgency allocation of the triage conversations were collected. The final diagnosis of each call was retrieved at the patient's general practice. Absolute numbers of patients with and without ACS were plotted and risks per hour were calculated. The risk ratio of ACS at night (0 to 9 am) was calculated by comparing to the risk at other hours and was adjusted for gender and age. RESULTS The mean age of callers was 58.9 (standard deviation ±19.5) years, 55.5% were women and, in total, 199 (12.0%) had an ACS. The crude risk ratio for an ACS at night was 1.80 (confidence interval 1.39-2.34, P < 0.001): 2.33 (1.68-3.22, P < 0.001) for men and 1.29 (0.83-1.99, P = 0.256) for women. The adjusted risk ratio for ACS of all people at night was 1.82 (1.07-3.10, P = 0.039). CONCLUSIONS Patients calling the OHS-PC for chest discomfort between 0 and 9 am have almost twice a higher risk of ACS than those calling other hours, a phenomenon more evident in men than in women. At night, dispatching ambulances more 'straightaway' could be considered for these patients with chest discomfort. TRIAL NUMBER NTR7331.
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Affiliation(s)
- Loes T Wouters
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Dorien L Zwart
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Daphne C Erkelens
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Noël S Cheung
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Esther de Groot
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Roger A Damoiseaux
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Arno W Hoes
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Frans H Rutten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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17
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Erkelens DC, Rutten FH, Wouters LT, de Groot E, Damoiseaux RA, Hoes AW, Zwart DL. Limited reliability of experts' assessment of telephone triage in primary care patients with chest discomfort. J Clin Epidemiol 2020; 127:117-124. [PMID: 32730853 DOI: 10.1016/j.jclinepi.2020.07.016] [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: 02/26/2020] [Revised: 07/02/2020] [Accepted: 07/23/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Root cause analyses of serious adverse events (SAE) in out-of-hours primary care (OHS-PC) often point to errors in telephone triage. Such analyses are, however, hampered by hindsight bias. We assessed whether experts, blinded to the outcome, recognize (un)safety of triage of patients with chest discomfort, and we quantified inter-rater reliability. STUDY DESIGN AND SETTING This is a case-control study with triage recordings from 2013-2017 at OHS-PC. Cases were missed acute coronary syndromes (ACSs, considered as SAE). These cases were age- and gender-matched 1:8 with the controls, sampled from the remainder of people calling for chest discomfort. Fifteen experts listened to the recordings and rated the safety of triage. We calculated sensitivity and specificity of recognizing an ACS and the intraclass correlation. RESULTS In total, 135 calls (15 SAE, 120 matched controls) were relistened. The experts identified ACSs with a sensitivity of 0.86 (95% CI: 0.71-0.95) and a specificity of 0.51 (95% CI: 0.43-0.58). Cases were rated significantly more often as unsafe than the controls (73.3% vs. 22.5%, P < 0.001). The inter-rater reliability for safety was poor: ICC 0.16 (95% CI: 0.00-0.32). CONCLUSIONS Blinded experts rated calls of missed ACSs more often as unsafe than matched control calls, but with a low level of agreement among the experts.
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Affiliation(s)
- Daphne C Erkelens
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
| | - Frans H Rutten
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Loes T Wouters
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Esther de Groot
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Roger A Damoiseaux
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Arno W Hoes
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Dorien L Zwart
- Department of General Practice, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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18
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Teragawa H, Oshita C, Orita Y. Is Noncardiac Chest Pain Truly Noncardiac? CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2020; 14:1179546820918903. [PMID: 32595282 PMCID: PMC7297489 DOI: 10.1177/1179546820918903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 03/15/2020] [Indexed: 11/16/2022]
Abstract
Many causes of noncardiac chest pain (NCCP) have been studied and gastroesophageal reflux disease is considered to be the major cause. However, studies have reported that treatment with a proton pump inhibitor does not effectively provide relief for NCCP-related symptoms, and these symptoms frequently recur. These findings suggest that patients with cardiac disease may be excluded completely from the NCCP group. Several examinations can be conducted to verify the presence of cardiac disease. Such examinations include the assessment of biochemical markers, rest and exercise electrocardiogram, echocardiography, cardiac computed tomography, stress myocardial perfusion imaging, cardiac magnetic resonance imaging, and coronary angiography (CAG). However, the presence of functional coronary artery diseases (CADs), such as vasospastic angina and/or microvascular angina, cannot be detected using these modalities. These functional CADs can be diagnosed by CAG with spasm-provocation testing and/or physiological coronary measurement. Thus, when a patient who is suspected of having NCCP takes a proton pump inhibitor and does not respond well, further examination-including assessment for possible functional CADs-may be needed.
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Affiliation(s)
- Hiroki Teragawa
- Department of Cardiovascular Medicine, JR Hiroshima Hospital, Hiroshima, Japan
| | - Chikage Oshita
- Department of Cardiovascular Medicine, JR Hiroshima Hospital, Hiroshima, Japan
| | - Yuichi Orita
- Department of Cardiovascular Medicine, JR Hiroshima Hospital, Hiroshima, Japan
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Gdowski MA, Murthy VL, Doering M, Monroy-Gonzalez AG, Slart R, Brown DL. Association of Isolated Coronary Microvascular Dysfunction With Mortality and Major Adverse Cardiac Events: A Systematic Review and Meta-Analysis of Aggregate Data. J Am Heart Assoc 2020; 9:e014954. [PMID: 32345133 PMCID: PMC7428565 DOI: 10.1161/jaha.119.014954] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background The impact of coronary microvascular dysfunction (CMD), as diagnosed by reduced coronary flow reserve, on the outcomes of patients with symptoms of myocardial ischemia and nonobstructive coronary artery disease is poorly understood. We performed a systematic review and meta-analysis of observational studies to determine the association of CMD with outcomes. Methods and Results We searched online databases for studies where coronary flow reserve was measured invasively or noninvasively, clinical events were recorded after determination of coronary flow reserve, and the frequency of those events was reported for patients with and without CMD. The primary outcome was all-cause mortality. The secondary outcome was major adverse cardiac events, including cardiac or cardiovascular death, nonfatal myocardial infarction, cardiac hospitalization, or coronary revascularization. Estimates of effect were calculated from crude event rates with a random-effects model. There were 122 deaths in the 4661 patients without CMD (2.6%) and 183 deaths in the 1970 patients with CMD (9.3%). The odds ratio for mortality in patients with CMD compared with those without CMD was 3.93 (95% CI, 2.91-5.30; P<0.001). There were 167 major adverse cardiac events in the 3742 patients without CMD (4.5%) and 245 events in the 1447 patients with CMD (16.9%). The odds ratio for major adverse cardiac events in patients with CMD compared with those without CMD was 5.16 (95% CI, 2.81-9.47; P<0.001). Conclusions CMD is associated with a nearly 4-fold increase in mortality and a 5-fold increase in major adverse cardiac events. Future studies are needed to identify effective strategies to diagnose and treat CMD.
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Affiliation(s)
- Mark A Gdowski
- Cardiovascular Division Washington University School of Medicine St. Louis MO.,Washington University School of Medicine St. Louis MO
| | | | | | - Andrea G Monroy-Gonzalez
- Medical Imaging Center Departments of Nuclear Medicine and Molecular Imaging and Radiology University of Groningen University Medical Center Groningen the Netherlands
| | - Riemer Slart
- Medical Imaging Center Departments of Nuclear Medicine and Molecular Imaging and Radiology University of Groningen University Medical Center Groningen the Netherlands.,TechMed Centre Department of Biomedical Photonic Imaging University of Twente Enschede the Netherlands
| | - David L Brown
- Cardiovascular Division Washington University School of Medicine St. Louis MO.,Washington University School of Medicine St. Louis MO
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20
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Mourad G, Alwin J, Jaarsma T, Strömberg A, Johansson P. The associations between psychological distress and health-related quality of life in patients with non-cardiac chest pain. Health Qual Life Outcomes 2020; 18:68. [PMID: 32160887 PMCID: PMC7066800 DOI: 10.1186/s12955-020-01297-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 02/13/2020] [Indexed: 12/21/2022] Open
Abstract
Background Recurrent chest pain episodes with no clear explanation may affect patients’ psychological wellbeing and health-related quality of life (HRQoL) negatively. Despite the fact that a significant amount of patients with non-cardiac chest pain (NCCP) might have a history of Cardiac Disease (CD), there is today a lack of knowledge on how CD influences the association between psychological wellbeing and HRQoL in patients with NCCP. Therefore, the aim of this study is to describe HRQoL in patients with NCCP, with or without history of CD, and to explore the association between HRQoL and cardiac anxiety, depressive symptoms, fear of body sensations and somatization. Methods Five hundred fifty-two patients discharged with NCCP from four hospitals in Southeast Sweden completed the EQ-5D, Cardiac Anxiety Questionnaire, Patient Health Questionnaire-9, Body Sensations Questionnaire, and Patient Health Questionnaire-15. Results Fifty precent reported at least moderate problems regarding pain/discomfort and 25% reported at least moderate problems in the HRQoL dimensions mobility, usual activities, and anxiety/depression. Patients with NCCP and history of CD reported significantly lower HRQoL (p ≤ 0.05) compared to patients with NCCP without CD. In the total study population, cardiac anxiety, depressive symptoms, and somatization had weak significant negative associations (beta = 0.187–0.284, p < 0.001) with HRQoL. In patients with history of CD, the association between depressive symptoms and HRQoL was moderate (beta = − 0.339, p < 0.001), compared to weak association in patients without CD (beta = − 0.193, p < 0.001). On the other hand, the association between cardiac anxiety and HRQoL was weak in both patients with history of CD (beta = − 0.156, p = 0.05), and in those without (beta = − 0.229, p < 0.001). Conclusions Patients with NCCP, in particular those with history of CD, reported low levels of HRQoL, which was associated with psychological distress. This should be considered when developing psychological interventions aiming to improve HRQoL in patients with NCCP.
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Affiliation(s)
- Ghassan Mourad
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.
| | - Jenny Alwin
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Tiny Jaarsma
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Anna Strömberg
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.,Department of Cardiology in Linköping, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Peter Johansson
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
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21
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van der Meer MG, Appelman Y, Rutten KHG, van der Graaf Y, Nathoe HM, Doevendans PA, Smit M, Verheij E, Botermans A, Rutten FH. Are there gender disparities in symptom presentation or triage of patients with chest discomfort at primary care out-of-hours services? An observational study. BMJ Open 2019; 9:e031613. [PMID: 31748303 PMCID: PMC6886986 DOI: 10.1136/bmjopen-2019-031613] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES Previous hospital-based studies have suggested delayed recognition of acute coronary syndrome (ACS) in women. We wanted to assess differences in symptom presentation or triage among women and men who contacted primary care out-of-hours services (OHS) for chest discomfort. DESIGN Retrospective observational study. SETTING Primary care OHS. PARTICIPANTS 276 women and 242 men with chest discomfort who contacted a primary care OHS in the Netherlands in 2013 and 2014. MAIN OUTCOME MEASURES Differences between women and men regarding symptom presentation and urgency allocation. RESULTS 8.4% women and 14.0% men had ACS. Differences in symptoms between patients with and without ACS were in general small, for both women and men. In women with ACS compared with women without ACS, mean duration of telephone calls was discriminative; 5.22 (SD 2.53) vs 7.26 (SD 3.11) min, p value=0.003. In men, radiation of pain (89.3% vs 54.9%, p value=0.011) was discriminative for ACS, and stabbing chest pain (3.7% vs 24.0%, p value=0.014) for absence of ACS . Women and men with chest discomfort received similar high urgency allocation (crude and adjusted OR after correction for ACS and age; 1.03 (95% CI 0.72 to 1.48) and 1.04 (95% CI 0.72 to 1.52), respectively). Women with ACS received a high urgency allocation in 22/23 (95.7%) and men with ACS in 30/34 (88.2%), p value=0.331. CONCLUSIONS Discriminating ACS in patients with chest discomfort who contacted primary care OHS is difficult in both women and men. Women and men with chest discomfort received similar high urgency allocation.
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Affiliation(s)
- Manon G van der Meer
- Cardiology, University Medical Center Utrecht, Utrecht, Utrecht, The Netherlands
| | - Yolande Appelman
- Amsterdam University Medical Centre, Location VU Medical Centre, VU University, Amsterdam, The Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Karlijn H G Rutten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | | | - Hendrik M Nathoe
- Cardiology, University Medical Center Utrecht, Utrecht, Utrecht, The Netherlands
| | - Pieter A Doevendans
- Cardiology, University Medical Center Utrecht, Utrecht, Utrecht, The Netherlands
| | - Michelle Smit
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Emmy Verheij
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Anne Botermans
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Frans H Rutten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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