Impact of more conservative European Society of Cardiology guidelines on the management of patients with acute chest pain

Kienbacher, Calvin; Fuhrmann, Verena; Tulder, Raphael van; Havel, Christof; Schreiber, Wolfgang; Rasoul‐Rockenschaub, Susanne; Wrba, Thomas; Herkner, Harald; Laggner, Anton N.; Roth, Dominik von

doi:10.1111/ijcp.14133

Cited by 3 publications

(1 citation statement)

References 26 publications

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“…This is important as only 11%-21% of these patients presenting to an emergency department are finally diagnosed with an NSTE-ACS, in the remaining majority generally no life-threatening condition is found. [12][13][14] Early risk assessment in these patients with low suspicion could significantly reduce the need of unnecessary diagnostics, referrals to hospitals, and therefore reduce healthcare cost.…”

Section: Strengths and Limitations Of This Studymentioning

confidence: 99%

Prehospital risk assessment in patients suspected of non-ST-segment elevation acute coronary syndrome: a systematic review and meta-analysis

et al. 2022

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ObjectiveTo review, inventory and compare available diagnostic tools and investigate which tool has the best performance for prehospital risk assessment in patients suspected of non-ST-segment elevation acute coronary syndrome (NSTE-ACS).MethodsSystematic review and meta-analysis. Medline and Embase were searched up till 1 April 2021. Prospective studies with patients, suspected of NSTE-ACS, presenting in the primary care setting or by emergency medical services (EMS) were included. The most important exclusion criteria were studies including only patients with ST-elevation myocardial infarction and studies before 1995, the pretroponin era. The primary end point was the final hospital discharge diagnosis of NSTE-ACS or major adverse cardiac events (MACE) within 6 weeks. Risk of bias was evaluated by the Quality Assessment of Diagnostic Accuracy Studies Criteria.Main outcome and measuresSensitivity, specificity and likelihood ratio of findings for risk stratification in patients suspected of NSTE-ACS.ResultsIn total, 15 prospective studies were included; these studies reflected in total 26 083 patients. No specific variables related to symptoms, physical examination or risk factors were useful in risk stratification for NSTE-ACS diagnosis. The most useful electrocardiographic finding was ST-segment depression (LR+3.85 (95% CI 2.58 to 5.76)). Point-of-care troponin was found to be a strong predictor for NSTE-ACS in primary care (LR+14.16 (95% CI 4.28 to 46.90) and EMS setting (LR+6.16 (95% CI 5.02 to 7.57)). Combined risk scores were the best for risk assessment in an NSTE-ACS. From the combined risk scores that can be used immediately in a prehospital setting, the PreHEART score, a validated combined risk score for prehospital use, derived from the HEART score (History, ECG, Age, Risk factors, Troponin), was most useful for risk stratification in patients with NSTE-ACS (LR+8.19 (95% CI 5.47 to 12.26)) and for identifying patients without ACS (LR−0.05 (95% CI 0.02 to 0.15)).DiscussionImportant study limitations were verification bias and heterogeneity between studies. In the prehospital setting, several diagnostic tools have been reported which could improve risk stratification, triage and early treatment in patients suspected for NSTE-ACS. On-site assessment of troponin and combined risk scores derived from the HEART score are strong predictors. These results support further studies to investigate the impact of these new tools on logistics and clinical outcome.FundingThis study is funded by ZonMw, the Dutch Organisation for Health Research and Development.Trial registration numberThis meta-analysis was published for registration in PROSPERO prior to starting (CRD York, CRD42021254122).

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Section: Strengths and Limitations Of This Studymentioning

confidence: 99%

Prehospital risk assessment in patients suspected of non-ST-segment elevation acute coronary syndrome: a systematic review and meta-analysis

et al. 2022

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Impact of more conservative European Society of Cardiology guidelines on the management of patients with acute chest pain

Kienbacher

Fuhrmann

Tulder

et al. 2021

Int J Clinical Practice

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Objective Early diagnosis or rule‐out of acute coronary syndrome (ACS) is a key competence of emergency medicine. Changes in the NSTE‐ACS guidelines of the European Society of Cardiology (ESC) in 2015 and 2020 both warranted a henceforth more conservative approach regarding high‐sensitivity troponin t (hsTnt) testing. We aimed to assess the impact of more conservative guidelines on the frequency of early rule‐out and prolonged observation with repeated hsTnt testing at a high‐volume tertiary care emergency department. Patients and Methods We conducted a pre‐ and post‐changeover analysis 3 months before and 3 months after transition from less (hsTnt cut‐off 30 ng/L, 3‐hour rule‐out) to more conservative (hsTnt cut‐off 14 ng/L, 1‐hour rule‐out) guidelines in 2015, comparing proportions of patients requiring repeated testing. Results We included 5442 cases of symptoms suspicious of acute cardiac origin (3451 before, 1991 after, 2370 (44%) female, age 55 (SD 19) years). The proportion of patients fulfilling early‐rule out criteria decreased from 68% (2348 patients) before to 60% (1195 patients) with the 2015 guidelines (P < .01). Those requiring repeated testing significantly (P < .01) increased from 22% (743 patients) to 25% (494 patients). Positive results in repeated testing significantly (P = .02) decreased from 43% (320 patients) to 37% (181 patients). Invasive diagnostics were performed in 91 patients (2.6%) before and in 75 patients (3.8%) after (P = .02) the guideline revision. Conclusion The implementation of the more conservative 2015 ESC guidelines led to a minor rise in prolonged observations because of an increase in negative repeated testing and to an increase in invasive procedures.

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The Use of Multiple Cardiovascular Ischemia Markers in the Diagnosis of Acute Coronary Syndrome

图尔荪古丽

2023

ACM

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Impact of more conservative European Society of Cardiology guidelines on the management of patients with acute chest pain

Cited by 3 publications

References 26 publications

Prehospital risk assessment in patients suspected of non-ST-segment elevation acute coronary syndrome: a systematic review and meta-analysis

Prehospital risk assessment in patients suspected of non-ST-segment elevation acute coronary syndrome: a systematic review and meta-analysis

Impact of more conservative European Society of Cardiology guidelines on the management of patients with acute chest pain

The Use of Multiple Cardiovascular Ischemia Markers in the Diagnosis of Acute Coronary Syndrome

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