Unexpected high level of severe events even in low-risk profile chest pain unit patients.

Frank Breuckmann,Stephan Settelmeier,Jochen Senges,Evangelos Giannitsis,Tienush Rassaf,Matthias Hochadel,Thomas Voigtländer,Bernd Nowak,Thomas Münzel

doi:10.1007/s00059-021-05064-9

Abstract

AimsEarly heart attack awareness programs are thought to increase efficacy of chest pain units (CPU) by providing live-saving information to the community. We hypothesized that self-referral might be a feasible alternative to activation of emergency medical services (EMS) in selected chest pain patients with a specific low-risk profile.Methods and resultsIn this observational registry-based study, data from 4743 CPU patients were analyzed for differences between those with or without severe or fatal prehospital or in-unit events (out-of-hospital cardiac arrest and/or in-unit death, resuscitation or ventricular tachycardia). In order to identify a low-risk subset in which early self-referral might be recommended to reduce prehospital critical time intervals, the Global Registry of Acute Coronary Events (GRACE) score for in-hospital mortality and a specific low-risk CPU score developed from the data by multivariate regression analysis were applied and corresponding event rates were calculated. Male gender, cardiac symptoms other than chest pain, first onset of symptoms and a history of myocardial infarction, heart failure or cardioverter defibrillator implantation increased propensity for critical events. Event rates within the low-risk subsets varied from 0.5–2.8%. Those patients with preinfarction angina experienced fewer events.ConclusionsWhen educating patients and the general population about angina pectoris symptoms and early admission, activation of EMS remains recommended. Even in patients without any CPU-specific risk factor, self-referral bears the risk of severe or fatal pre- or in-unit events of 0.6%. However, admission should not be delayed, and self-referral might be feasible in patients with previous symptoms of preinfarction angina.

Highlights

Patients with acute severe chest pain longer than five minutes are advised to consider a myocardial infarction and to activate the emergency medical services (EMS) without any delay
Whereas parameters such as family history for coronary artery disease or conventional risk factors remained without significant impact, patients with documented life-threatening or fatal events were younger, more often male, more often with a history of myocardial infarction, bypass graft placement or cardioverter defibrillator implantation and more often known to have renal impairment
The rates of life-threatening or fatal events varied between 0.6% in the absence of any risk factor to 2.8% when scored with 3 points only

Summary

Introduction

Patients with acute severe chest pain longer than five minutes are advised to consider a myocardial infarction and to activate the emergency medical services (EMS) without any delay. As of March 2020, the German Cardiac Society (DGK) had certified a total of 287 chest pain units (CPUs), establishing a nationwide network across Germany [3,4,5]. The certification process is centrally organized by the DGK [6]. Key elements of the certification process include characteristic locations, equipment, diagnostic and therapeutic strategies, cooperation, staff education, and organization [4, 7, 8]. The efficacy in patient care as well as guideline adherence has been proven by a number of studies originating from the German CPU registry [9]. The Acute Cardiovascular Care Association published an evidence-based framework for the development of standardized

Results

Discussion

Conclusion