Clinical assessment of patients with chest pain; a systematic review of predictive tools

Vascular medicine in the 21st century: Embracing comprehensive vasculature evaluation and multidisciplinary treatment

The field of vascular medicine has undergone a profound transformation in the 21^st century, transforming our approach to assessment and treatment. Atherosclerosis, a complex inflammatory disease that affects medium and large arteries, presents a major challenge for researchers and healthcare professionals. This condition, characterized by arterial plaque formation and narrowing, poses substantial challenges to vascular health at individual, national, and global scales. Its repercussions are far-reaching, with clinical outcomes including ischemic heart disease, ischemic stroke, and peripheral arterial disease—conditions with escalating global prevalence. Early detection of vascular changes caused by atherosclerosis is crucial in preventing these conditions, reducing morbidity, and averting mortality. This article underscored the imperative of adopting a holistic approach to grappling with the intricacies, trajectories, and ramifications of atherosclerosis. It stresses the need for a thorough evaluation of the vasculature and the implementation of a multidisciplinary treatment approach. By considering the entire vascular system, healthcare providers can explore avenues for prevention, early detection, and effective management of this condition, ultimately leading to improved patient outcomes. We discussed current practices and proposed new directions made possible by emerging diagnostic modalities and treatment strategies. Additionally, we considered healthcare expenditure, resource allocation, and the transformative potential of new innovative treatments and technologies.

Incidental findings of acute myocardial infarction detected during ECG-gated and nongated thoracic CTA: A report of four cases

Worldwide, myocardial infarction is a leading cause of mortality and disability. The phrase ``myocardial infarction'' refers to ischemia, which is the outcome of an imbalance in perfusion between supply and demand and results in the death of cardiac myocytes Myocardial ischemia is often diagnosed based on the patient's medical history and electrocardiogram (ECG) findings. Potential ischemic symptoms include a variety of chest, upper extremity, jaw, or epigastric pain or discomfort that typically lasts at least 20 minutes, is diffuse, not positional, not localized, not dependent on movement of the area, and may be accompanied by syncope, dyspnea, or nausea. These symptoms can occur at rest or after physical activity. These symptoms may be mistaken for other conditions since they are not specific to myocardial ischemia. Radiologists play a crucial role in this scenario since imaging is increasingly being used to identify and categorize these individuals. We report 4 cases of myocardial infarction presenting without chest pain and discovered incidentally during imaging tests.

Prediction of significant coronary artery disease in acute chest pain without infarction in emergency department: MAPAC Cardio-PreTest model

Acute nontraumatic chest pain is a frequent reaso n for consultation in emergency departments and represents a diagnostic challenge. The objective is to estimate the risk of significant coronary artery disease (CAD) in patients with cardiogenic acute chest pain for whom the diagnosis of infarction was ruled out in the emergency department with a nondiagnostic ECG and negative high-sensitivity troponins. We prospectively recruited 1625 patients from emergency departments of seven Spanish hospitals. The outcome was presence of significant CAD determined by presence of ischaemia in functional tests or more than 70% stenosis in imaging tests. In this study, we developed a predictive model and evaluated its performance and clinical utility. The prevalence of significant CAD was 14% [227/1625; 95% confidence interval (CI), 12-16]. MAPAC Cardio-PreTest model included seven predictors: age, sex, smoking, history of hypertension, family history of CAD, history of hyperuricaemia, and type of chest pain. The optimism-adjusted model discrimination was C-statistic 0.654 (95% CI, 0.618-0.693). Calibration plot showed good agreement between the predicted and observed risks, and calibration slope was 0.880 (95% CI, 0.731-1.108) and calibration-in-the-large -0.001 (95% CI, -0.141 to 0.132). The model increased net benefit and improved risk classification over the recommended approach by the European Society of Cardiology [Net Reclassification Index (NRI) of events = 5.3%, NRI of nonevents = 7.0%]. MAPAC Cardio-PreTest model is an online prediction tool to estimate the individualised probability of significant CAD in patients with acute chest pain without a diagnosis of infarction in emergency department. The model was more useful than the current alternatives in helping patients and clinicians make individually tailored choices about the intensity of monitoring or additional coronary tests.

Improving performance and self‐efficacy of novice nurses using hybrid simulation‐based mastery learning

AIM

Acute chest pain is a commonly encountered symptom in hospital medical/surgical units; however, almost half of nurses in their second year of clinical experience in our facility have reported struggling to care for acute chest pain patients. We developed, implemented, and examined the effectiveness of a simulation-based, mastery learning clinical nursing educational program to improve self-efficacy and performance in caring for patients with acute chest pain.

METHODS

The study adopted a single-site, single-cohort design using simulation-based performance assessment and self-efficacy surveys on a convenience sample of 37 second-year clinical nurse participants in multi-stage hybrid mastery learning educational intervention using asynchronous e-learning, and hands-on simulation training and assessment with feedback on caring for chest pain patients. Performance assessments and self-efficacy surveys were administered pre-, post-, and 5 months post-intervention.

RESULTS

Clinical performance on the post- and 5 months follow-up assessments were significantly higher than those for the pre-test (P < .0001). The self-efficacy scores for the post- and the 5 months follow-up assessments were significantly higher than the pre-course scores (P < .0001). Participants' self-efficacy perceptions were positively correlated with their performances at 5 months post-intervention.

CONCLUSION

Performance and self-efficacy of novice nurses in caring for acute chest pain patients improved significantly with the multi-stage hybrid mastery learning educational intervention, with improvements retained 5 months post-intervention. The results suggest the applicability of simulation-based mastery learning in a clinical setting for novice nurses to attain specific skills, and raise their self-perception of competence to care for patients in acute settings.

Predictors of long-term symptom burden and quality of life in patients hospitalised with chest pain: a prospective observational study

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.

Evaluation and comparison of six GRACE models for the stratification of undifferentiated chest pain in the emergency department

Background

The Global Registry of Acute Coronary Events (GRACE) score is recommended for stratifying chest pain. However, there are six formulas used to calculate the GRACE score for different outcomes of acute coronary syndrome (ACS), including death (Dth) or composite of death and myocardial infarction (MI), while in hospital (IH), within 6 months after discharge (OH6m) or from admission to 6 months later (IH6m). We aimed to perform the first comprehensive evaluation and comparison of six GRACE models to predict 30-day major adverse cardiac events (MACEs) in patients with acute chest pain in the emergency department (ED).

Methods

Patients with acute chest pain were consecutively recruited from August 24, 2015 to September 30, 2017 from the EDs of two public hospitals in China. The 30-day MACEs included death, acute myocardial infarction (AMI), emergency revascularization, cardiac arrest and cardiogenic shock. The correlation, calibration, discrimination, reclassification and diagnostic accuracy at certain cutoff values of six GRACE models were evaluated. Comparisons with the History, ECG, Age, Risk Factors, and Troponin (HEART) and Thrombolysis in Myocardial Infarction (TIMI) scores were conducted.

Results

A total of 2886 patients were analyzed, with 590 (20.4%) patients experiencing outcomes. The GRACE (IHDthMI), GRACE (IH6mDthMI), GRACE (IHDth), GRACE (IH6mDth), GRACE (OH6mDth) and GRACE (OH6mDthMI) showed positive linear correlations with the actual MACE rates (r ≥ 0.568, P < 0.001). All these models had good calibration (Hosmer-Lemeshow test, P ≥ 0.073) except GRACE (IHDthMI) (P < 0.001). The corresponding C-statistics were 0.83(0.81,0.84), 0.82(0.81,0.83), 0.75(0.73,0.76), 0.73(0.72,0.75), 0.72(0.70,0.73) and 0.70(0.68,0.71), respectively, first two of which were comparable to HEART (0.82, 0.80–0.83) and superior to TIMI (0.71, 0.69–0.73). With a sensitivity ≥95%, GRACE (IHDthMI) ≤81 and GRACE (IH6mDthMI) ≤79 identified 868(30%) and 821(28%) patients as low risk, respectively, which were significantly better than other GRACEs and HEART ≤3(22%). With a specificity ≥95%, GRACE (IHDthMI) > 186 and GRACE (IH6mDthMI) > 161 could recognize 12% and 11% patients as high risk, which were greater than other GRACEs, HEART ≥8(9%) and TIMI ≥5(8%).

Conclusions

In this Chinese setting, certain strengths of GRACE models beyond HEART and TIMI scores were still noteworthy for stratifying chest pain patients. The validation and reasonable application of appropriate GRACE models in the evaluation of undifferentiated chest pain should be recommended.

Enhanced triage for patients with suspected cardiac chest pain: the History and Electrocardiogram-only Manchester Acute Coronary Syndromes decision aid

Supplemental Digital Content is available in the text.

Several decision aids can ‘rule in’ and ‘rule out’ acute coronary syndromes (ACS) in the Emergency Department (ED) but all require measurement of blood biomarkers. A decision aid that does not require biomarker measurement could enhance risk stratification at triage and could be used in the prehospital environment. We aimed to derive and validate the History and ECG-only Manchester ACS (HE-MACS) decision aid using only the history, physical examination and ECG.

The Analgesic Effect of Oxygen in Suspected Acute Myocardial Infarction: A Substudy of the DETO2X-AMI Trial

OBJECTIVES

In this substudy of the DETO2X-AMI (An Efficacy and Outcome Study of Supplemental Oxygen Treatment in Patients With Suspected Myocardial Infarction) trial, the authors aimed to assess the analgesic effect of moderate-flow oxygen supplementation in patients with suspected acute myocardial infarction (AMI) treated with percutaneous coronary intervention (PCI) and to study the effect of oxygen supplementation on the use of opiates and sedatives during PCI.

BACKGROUND

Routine oxygen in normoxemic patients with AMI does not provide clinical benefit. However, oxygen may relieve ischemic pain.

METHODS

Patients were randomly allocated to oxygen or ambient air according to the main study protocol. After PCI, peak level of pain during PCI was measured by the Visual Analogue Scale. The total amount of opiates and sedatives was reported.

RESULTS

A total of 622 patients were enrolled: 330 in the oxygen group and 292 in the ambient air group. There was no significant difference in peak level of pain (oxygen 4.0 [1.0 to 6.0] vs. air 3.0 [0.6 to 6.0]; p = 0.37), use of opiates (mg) (oxygen 0.0 [0.0 to 3.0] vs. air 0.0 [0.0 to 3.0]; p = 0.31), or use of sedatives between the groups (median [interquartile range]) (oxygen 2.5 [0.0 to 2.5] vs. air 2.5 [0.0 to 2.5]; p = 0.74).

CONCLUSIONS

In the present study, the authors did not find any analgesic effect of routine oxygen as compared with ambient air, and no differences in the use of sedatives and opiates during PCI. Our results indicate that moderate-flow oxygen supplementation does not relieve pain in normoxemic patients with suspected AMI undergoing treatment with PCI and should thus not be used for this purpose.

Association of Search Engine Queries for Chest Pain With Coronary Heart Disease Epidemiology

Importance

Online search for symptoms is common and may be useful in early identification of patients experiencing coronary heart disease (CHD) and in epidemiologically studying the disease.

Objective

To investigate the correlation of online symptom search for chest pain with disease prevalence of CHD.

Design, Setting, and Participants

This retrospective study used Google Trends, a publicly available tool that provides relative search frequency for queried terms, to find searches for chest pain from January 2010 to June 2017 in the United States, the United Kingdom, and Australia. For the United States, results were obtained by state. These data were compared with publicly available prevalence data from the US Centers for Disease Control and Prevention of CHD hospitalizations by state for the same period. The same terms were used to evaluate seasonal and diurnal variation. Data were analyzed from July 2017 to October 2017.

Main Outcomes and Measures

Correlation of search engine query for chest pain symptoms with temporal and geographic epidemiology.

Results

State-by-state comparisons with reported CHD hospitalization were correlated (R = 0.81; P < .001). Significant monthly variation was appreciated in all countries studied, with the United States, United Kingdom, and Australia showing an 11% to 39% increase in search frequency in winter months compared with summer months. Diurnal variation showed a morning peak for search between local time 6 am and 8 am, with a greater than 100% increase seen in peak searching hours, which was consistent among the 3 countries studied.

Conclusions and Relevance

Relative search frequency closely correlated with CHD epidemiology. This may have important implications for search engines as a resource for patients and a potential early-detection mechanism for physicians moving forward.

Using a structured clinical assessment to identify the cause of chest pain

Chest pain is a common reason for patient presentation to emergency departments and visits to primary care settings. While most causes of chest pain are not life-threatening, a small proportion require urgent intervention, particularly cardiac conditions such as acute coronary syndrome. Therefore, it is essential for healthcare practitioners, including nurses, to identify the cause of chest pain in a safe, timely and effective manner. This article outlines the main causes of chest pain and describes the aspects of chest pain assessment, including patient history-taking, physical examination and clinical investigations. Assessing chest pain requires healthcare practitioners to have knowledge of its causes and pathophysiology, the use of structured assessment tools and the latest evidence-based guidelines.

Chest pain in general practice: a systematic review of prediction rules

OBJECTIVE

To identify and assess the performance of clinical decision rules (CDR) for chest pain in general practice.

DESIGN

Systematic review of diagnostic studies.

DATA SOURCES

Medline/Pubmed, Embase/Ovid, CINAHL/EBSCO and Google Scholar up to October 2018.

STUDY SELECTION

Studies that assessed CDRs for intermittent-type chest pain and for rule out of acute coronary syndrome (ACS) applicable in general practice, thus not relying on advanced laboratory, computer or diagnostic testing.

REVIEW METHODS

Reviewers identified studies, extracted data and assessed the quality of the evidence (using Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2)), independently and in duplicate.

RESULTS

Eight studies comprising five CDRs met the inclusion criteria. Three CDRs are designed for rule out of coronary disease in intermittent-type chest pain (Gencer rule, Marburg Heart Score, INTERCHEST), and two for rule out of ACS (Grijseels rule, Bruins Slot rule). Studies that examined the Marburg Heart Score had the highest methodological quality with consistent sensitivity (86%-91%), specificity (61%-81%) and positive (23%-35%) and negative (97%-98%) predictive values (PPV and NPV). The diagnostic performance of Gencer (PPV: 20%-34%, NPV: 95%-99%) and INTERCHEST (PPV: 35%-43%, NPV: 96%-98%) appear comparable, but requires further validation. The Marburg Heart Score was more sensitive in detecting coronary disease than the clinical judgement of the general practitioner. The performance of CDRs that focused on rule out of ACS were: Grijseels rule (sensitivity: 91%, specificity: 37%, PPV: 57%, NPV: 82%) and Bruins Slot (sensitivity: 97%, specificity: 10%, PPV: 23%, NPV: 92%). Compared with clinical judgement, the Bruins Slot rule appeared to be safer than clinical judgement alone, but the study was limited in sample size.

CONCLUSIONS

In general practice, there is currently no clinical decision aid that can safely rule out ACS. For intermittent chest pain, several rules exist, of which the Marburg Heart Score has been most extensively tested and appears to outperform clinical judgement alone.

Managing chest pain patients in general practice: an interview-based study

Background

Assessment of chest pain in general practice is challenging. General practitioners (GPs) often feel uncertainty when dealing with chest pain. The role of new diagnostic tools is yet unclear.

Therefore, we aimed to learn: (1) whether or not GPs experience a change in incidence and presentation of chest pain, (2) how GPs deal with uncertainty, and (3) which thoughts, demands and doubts concerning new diagnostic tools occur.

Methods

Semi-structured, face to face interview based study, aiming at six main subjects: experienced changes in prevalence of chest pain, the management of chest pain patients, dealing with uncertainty, the GPs’ approach in referring chest pain patients, GPs’ attitude towards ‘unnecessary’ referrals, and the GPs’ suggestions for improving the management of chest pain patients.

Results

145 GPs in Belgium and the Netherlands were invited to participate, 27 (15 Flemish and 12 Dutch) GPs were interviewed. Data saturation was reached. The number of patients having an acute coronary syndrome among chest pain patients is decreasing, whereas the presentation of atypical complaints increases, together leading to more uncertainty. GPs rely on their own judgment above all, and desire new diagnostic tools only when these tools are of proven added value.

Conclusion

The incidence of chest pain in general practice is not decreasing according to the GPs. However, the presentation of chest pain is changing. GPs feel relatively comfortable with referring a considerable number of chest pain patients without ACS, as over-referral is safe. Uncertainty is regarded as a substantial element of their profession. New diagnostic tools are awaited with cautiousness.

Electronic supplementary material

The online version of this article (10.1186/s12875-018-0771-0) contains supplementary material, which is available to authorized users.

Chest Pain Patients at Veterans Hospitals Are Increasingly More Likely to Be Observed Than Admitted for Short Stays

Observation stays are an outpatient service used to diagnose and treat patients for extended periods of time while a decision is made regarding inpatient admission or discharge. Although the use of observation stays is increasing, little is known about which patients are observed and which are admitted for similar periods of time as inpatients. The aim was to identify patient characteristics associated with being observed rather than admitted for a short stay (<48 hours) within the Veterans Health Administration (VHA). In our longitudinal analysis, we used logistic regression within a generalized estimating equation framework to model observation stays as a function of patient characteristics, time trends, and hospital fixed effects. To minimize heterogeneity between groups, we limit our sample to patients with a presenting diagnosis of chest pain. Our analysis includes a total of 121 584 hospital events, which consist of all observation and short-stay admissions for chest pain patients at VHA hospitals between 2005 and 2013. Both the absolute and relative use of observation stays increased markedly over time. The odds of an observation stay were higher among women, but lower among older patients and rural residents. Despite strong evidence that chest pain patients are increasingly more likely to be observed than admitted, suggesting a substitution effect, we find little evidence of within-hospital disparities in VHA observation stay use.

Prehospital factors associated with an acute life-threatening condition in non-traumatic chest pain patients - A systematic review

BACKGROUND

Chest pain is a common symptom among patients contacting the emergency medical services (EMS). Risk stratification of these patients is warranted before arrival in hospital, regarding likelihood of an acute life-threatening condition (LTC).

AIM

To identify factors associated with an increased risk of acute LTC among patients who call the EMS due to non-traumatic chest pain.

METHODS

Several databases were searched for relevant articles. Identified articles were quality-assessed using the Scottish Intercollegiate Guidelines Network checklists. Extracted data was analysed using a semi-quantitative synthesis evaluating the level of evidence of each identified factor.

RESULTS

In total, 10 of 1245 identified studies were included. These studies provided strong evidence for an increased risk of an acute LTC with increasing age, male gender, elevated heart rate, low systolic blood pressure and ST elevation or ST depression on a 12-lead ECG. The level of evidence regarding the history of myocardial infarction, angina pectoris or presence of a Q wave or a Left Bundle Branch Block on the ECG was moderate. The evidence was inconclusive regarding dyspnoea, cold sweat/paleness, nausea/vomiting, history of chronic heart failure, smoking, Right Bundle Branch Block or T-inversions on the ECG.

CONCLUSIONS

Factors reflecting age, gender, myocardial ischemia and a compromised cardiovascular system predicted an increased risk of an acute life-threatening condition in the prehospital setting in cases of acute chest pain. These factors may form the basis for prehospital risk stratification in acute chest pain.