Acute Chest Pain—Diagnostic Accuracy and Pre-hospital Use of Anticoagulants and Platelet Aggregation Inhibitors.

Abstract

Acute chest pain (aCP) can be a symptom of life-threatening diseases such as acute coronary or aortic syndrome; however, aCP often is not of cardiac origin. The current recommendations for pre-hospital drug treatment in patients with aCP are unclear. We conducted a retrospective cohort study of 822 patients with aCP who were treated by emergency physicians (EP). The causes of aCP were classified as follows: non-ST-segment elevation acute coronary syndrome (NSTE-ACS), acute aortic syndrome, hypertensive crisis, cardiac arrhythmia, musculoskeletal causes, and other causes. The suspected diagnoses on admission were compared with the discharge diagnoses, and the pre-hospital administration of acetylsalicylic acid (ASA) and unfractionated heparin (UFH) was analyzed. It was also investigated which parameters improved diagnostic accuracy. The positive predictive value of diagnosis by an EP was 39.7%. NSTE-ACS was the most common suspected diagnosis (74.7%), but was confirmed in the hospital in only 26.3% of cases. ASA was administered in 51%, UFH in 55%, and both drugs in 46.4% of cases. Many patients whose in-hospital diagnosis was not NSTE-ACS had been treated with anticoagulants before their arrival in the hospital: ASA in 62.9% of cases, UFH in 66.0%, and both in 56.5%. Despite low pre-hospital diagnostic accuracy, ASA and UFH are often given to patients with acute chest pain who are treated by EPs before their arrival in the hospital. The pre-hospital measurement of hsTrop-T might help differentiate NSTE-ACS from other causes of acute chest pain. This is important, because current guidelines do not provide clear recommendations for the pre-hospital pharmacotherapy of NSTE-ACS.