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Cardiac, possible cardiac, and likely non-cardiac origin of chest pain

A hitherto underestimated parameter in German chest pain units

Kardialer, möglicherweise kardialer und wahrscheinlich nicht kardialer Thoraxschmerz

Ein bislang unterschätzter Parameter in deutschen Chest Pain Units

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Abstract

Background

Current guidelines emphasize the diagnostic value of non-cardiac or possibly cardiac chest pain. The goal of this analysis was to determine whether German chest pain units (CPUs) adequately address conditions with “atypical” chest pain in existing diagnostic structures.

Method

A total of 11,734 patients from the German CPU registry were included. The analyses included mode of admission, critical time intervals, diagnostic steps, and differential diagnoses.

Results

Patients with unspecified chest pain were younger, more often female, were less likely to have classic cardiovascular risk factors and tended to present more often as self-referrals. Patients with acute coronary syndrome (ACS) mostly had prehospital medical contact. Overall, there was no difference between these two groups regarding the time from the onset of first symptoms to arrival at the CPU. In the CPU, the usual basic diagnostic measures were performed irrespective of ACS as the primary working diagnosis. In the non-ACS group, further ischemia-specific diagnostics were rarely performed. Extra-cardiac differential diagnoses were not specified.

Conclusion

The establishment of broader awareness programs and opening CPUs for low-threshold evaluation of self-referring patients should be discussed. Regarding the rigid focus on the clarification of cardiac causes of chest pain, a stronger interdisciplinary approach should be promoted.

Zusammenfassung

Hintergrund

Aktuelle Leitlinien betonen die diagnostische Wertigkeit auch des nichtkardialen oder möglicherweise nichtkardialen Thoraxschmerzes. In der aktuellen Arbeit wird untersucht, ob die deutschen Chest Pain Units (CPU) Erkrankungen mit „atypischen“ Brustschmerzen innerhalb der bestehender Diagnosestrukturen bereits angemessen behandeln.

Methode

Eingeschlossen wurden 11.734 Patienten aus dem deutschen CPU-Register. Die Analysen umfassten Aufnahmeart, kritische Zeitintervalle, diagnostische Schritte und Differenzialdiagnosen.

Ergebnisse

Patienten mit nicht näher bezeichneten Brustschmerzen waren jünger, häufiger weiblich, wiesen seltener klassische kardiovaskuläre Risikofaktoren auf und stellten sich tendenziell häufiger als Selbsteinweiser vor. Patienten mit akutem Koronarsyndrom (ACS) hatten meist bereits präklinischen Kontakt zum Gesundheitssystem. Insgesamt gab es keinen Unterschied hinsichtlich des Auftretens der ersten Symptome bis zum Eintreffen in der CPU. Innerhalb der CPU wurden bei allen Patienten und unabhängig von der initialen Arbeitsdiagnose ACS die üblichen Basisdiagnostikmaßnahmen durchgeführt. In der Nicht-ACS-Gruppe wurde selten weitere Ischämiediagnostik durchgeführt. Extrakardiale Differenzialdiagnosen wurden nicht weiter differenziert.

Schlussfolgerung

Die Einrichtung umfassenderer Awarenessprogramme und die niederschwellige Selbstvorstellungsmöglichkeit in die CPU sollten intensiver diskutiert werden. Angesichts der häufig starren Fokussierung auf die Abklärung ischämischer/kardialer Ursachen des akuten Thoraxschmerzes sollte ein stärkerer interdisziplinärer Ansatz gefördert werden.

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Acknowledgements

We are indebted to all participating CPUs and CPU patients.

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Authors and Affiliations

  1. Department of Cardiology, Pneumology, Neurology and Intensive Care, Klinik Kitzinger Land, Kitzingen, Germany

    Sebastian Imhof &  Frank Breuckmann

  2. Institute for Myocardial Infarction Research Foundation, Ludwigshafen, Germany

    Matthias Hochadel & Jochen Senges

  3. Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany

    Stavros Konstantinides

  4. CCB, Cardioangiologisches Centrum Bethanien, Frankfurt am Main, Germany

    Thomas Voigtländer & Bernd Nowak

  5. Clinic for Cardiology and Angiology, Municipal Hospital Karlsruhe, Karlsruhe, Germany

    Claus Schmitt

  6. Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center Essen, University Duisburg-Essen, Essen, Germany

    Tienush Rassaf &  Frank Breuckmann

  7. Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University Mainz, Mainz, Germany

    Thomas Münzel

  8. 3rd Department of Medicine, University Hospital Heidelberg, Heidelberg, Germany

    Evangelos Giannitsis

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  1. Sebastian Imhof
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Correspondence to Frank Breuckmann.

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Conflict of interest

S. Imhof, M. Hochadel, S. Konstantinides, T. Voigtländer, C. Schmitt, B. Nowak, T. Rassaf, J. Senges, T. Münzel, E. Giannitsis and F. Breuckmann declare that they have no competing interests.

For this article no studies with human participants or animals were performed by any of the authors. All studies mentioned were in accordance with the ethical standards indicated in each case.

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Imhof, S., Hochadel, M., Konstantinides, S. et al. Cardiac, possible cardiac, and likely non-cardiac origin of chest pain. Herz (2023). https://doi.org/10.1007/s00059-023-05230-1

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