Chest discomfort at night and risk of acute coronary syndrome: cross-sectional study of telephone conversations

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.

Nt-Probnp in Patients with Acute Myocardial Infarction Without Heart Failure

“…Wouters and collegues showed influence of time onset of chest pain on risk of ACS. Patients with chest pain between 0 and 9 AM have twice higher risk of ACS than those with chest pain in other hours (5).…”

Development and validation of a prediction rule for patients suspected of acute coronary syndrome in primary care: a cross-sectional study

“… 32 A new predictor is calling at night (between 00.00 and 09.00). 19 Previous studies in the ED setting also showed circadian variability with an early morning peak for ACS patients. 34 Finally, symptoms associated with ACS were rather similar between females and males, which is in line with recent sex-stratified studies of patients with chest discomfort who called the OHS-PC, but is in contrast with the prevailing opinion.…”

“…Also the INTERCHEST rule included pressing heavy chest pain as predictor 32. A new predictor is calling at night (between 00.00 and 09.00) 19. Previous studies in the ED setting also showed circadian variability with an early morning peak for ACS patients 34.…”

“…Patient (age, sex) and call characteristics (call time, call duration) were collected from the OHS-PC electronic medical files of the patients. As candidate predictors we included age and sex, the NTS triage criteria (see online supplemental appendix table 2), the ACS predictors from the modified Grijseels prediction model (male sex, radiation, nausea, sweating and history of CAD), the ‘CAD predictors’ from MHS and INTERCHEST prediction models (age, pain feels like pressure, CAD history or cardiovascular (CV) risk factors, patient assumes cardiac origin of pain), and—based on a recent own study in OHS-PC—the predictor ‘calling at night between 00:00 and 09:00’ 7–9 19…”

Towards enhanced telephone triage for chest pain: a Delphi study to define life-threatening conditions that must be identified

“…These include acute coronary syndrome (ACS), aortic dissection, pulmonary embolism (PE) [ 3 – 5 ], tension pneumothorax and pericarditis [ 5 ]. On the contrary, other causes of chest pain do not require urgent attention, such as many musculoskeletal, respiratory, psychiatric and gastrointestinal aetiologies [ 6 ]. The majority of patients with a primary complaint of chest pain who are transported to hospital by emergency ambulance are ultimately diagnosed with non-cardiac disease and do not require hospitalisation for treatment of their condition [ 1 , 7 , 8 ].…”