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

Abstract

BackgroundAssessment 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.MethodsSemi-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.Results145 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.ConclusionThe 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 materialThe online version of this article (10.1186/s12875-018-0771-0) contains supplementary material, which is available to authorized users.

Embracing complexity with systems thinking in general practitioners' clinical reasoning helps handling uncertainty

“…Even more important, as people age, most disease presentations develop simultaneously, but at different rates. With increasing age, disease phenotypes become more heterogeneous and different from the prototypical descriptions 13,14 . Moreover, these atypical disease presentations cause complex interactions, which greatly hinder GPs' ability to recognize the underlying diseases.…”

“…With increasing age, disease phenotypes become more heterogeneous and different from the prototypical descriptions. 13 , 14 Moreover, these atypical disease presentations cause complex interactions, which greatly hinder GPs' ability to recognize the underlying diseases. For example, the interacting symptoms anxiety, cognitive decline, and cachexia in older persons are often related to heart failure or dementia, or both, though cachexia is classically directly related to cancer.…”

De huisarts is een prima sneltest bij pijn op de borst

“…Zij stellen dat het klassieke myocardinfarct in de huisartsenpraktijk een zeldzaamheid is geworden. 8 Pathofysiologische en op ervaringen gebaseerde argumenten wijzen er dus op dat het ACS zich steeds minder in zijn typische gedaante voordoet, niet alleen bij vrouwen. Het klassieke beeld van het infarct dat Netter ooit heeft vereeuwigd lijkt steeds meer een historisch plaatje te worden en het is niet langer een beeld waarop de huisarts kan varen [figuur 2].…”

Evaluating possible acute coronary syndrome in primary care: the value of signs, symptoms, and plasma heart-type fatty acid-binding protein (H-FABP). A diagnostic study

“…1 Among these patients, cases of ACS are largely outnumbered by less severe causes of chest pain. [1][2][3][4][5] Yet, to avoid missing ACS, the GP's threshold to refer patients with chest pain is low. 1,[5][6][7] To reduce ACS-negative referrals in primary care and thereby diminish costs and patient discomfort -without a rise in missed cases of ACS -a CDR based on a clinical score of signs, symptoms, and POC biomarker testing detecting myocardial cell damage (such as high-sensitive cardiac troponin [hs-cTn] or H-FABP) is desirable.…”

“…[1][2][3][4][5] Yet, to avoid missing ACS, the GP's threshold to refer patients with chest pain is low. 1,[5][6][7] To reduce ACS-negative referrals in primary care and thereby diminish costs and patient discomfort -without a rise in missed cases of ACS -a CDR based on a clinical score of signs, symptoms, and POC biomarker testing detecting myocardial cell damage (such as high-sensitive cardiac troponin [hs-cTn] or H-FABP) is desirable. 3,[8][9][10][11][12][13][14][15][16][17] A potential role for H-FABP POC testing was earlier found using a cut-off value of 4 ng/ml, in an emergency department setting.…”