Purpose. Correct prehospital diagnosis of ischaemic heart disease (IHD) may accelerate and improve the treatment. We sought to evaluate the accuracy of prehospital diagnoses of ischemic heart diseases assigned by physicians. Methods. The Mobile Emergency Care Unit (MECU) in Odense, Denmark, services a population of 260.000. All admissions in 2009 concerning patients diagnosed in the IHD category were assessed. Outcome and diagnosis of each patient were manually validated in accordance to the final diagnosis established following admission to hospital, using the discharge summary from the relevant department as reference. Results. 428 MECU runs with a prehospital diagnosis of IHD were registered. 422 of these were included in the study and 354 of those patients were suitable for this analysis. 73,4% of the patients hospitalized with a prehospital diagnosis of IHD were initially admitted to the relevant ward. Of these patients, 40,0% had their preliminary diagnosis of IHD confirmed. 14,1% of all patients admitted to the hospital were diagnosed with nonheart conditions. Preliminary diagnoses of STEMI had an accuracy of 87,5%. Conclusions. The preliminary IHD diagnoses assigned by the MECU physicians were acceptable. In case of STEMI patients the diagnostic accuracy was excellent. In this study there was an apparent overtriage. 1. Background Ischaemic heart disease (IHD) as a part of a general cardiovascular disease is the leading cause of death in Denmark and the leading cause of admission to hospitals in Denmark [1]. Other industrial countries follow the same pattern [2]. Large randomised trials have demonstrated that fibrinolytic therapy can reduce mortality in patients with suspected acute myocardial infarction (AMI) [3]. Furthermore, it is known that reducing time to reperfusion decreases morbidity and mortality [3, 4]. This knowledge calls for making a fast assessment of the patient’s risk of having acute coronary syndrome (ACS). The simple solution to this problem is to admit all patients, even the ones with low suspicion of acute ischaemia, to specialized cardiac centres. This concept, “Chest Pain Clinics,” is increasingly gaining acceptance, but there are potential drawbacks to sending all patients with chest pain to the same department, regardless of eliciting factor. This practice may lead to a poor cost-effectiveness and overtriage. To eliminate these drawbacks, a diagnostic tool is needed to separate the patients in need of fibrinolytic therapy from other patients. This is yet to be discovered and often the decision to admit a patient to a
References
[1]
N. K. Nielsen and S. Rasmussen, “Heart statistics—focus on gender and social differences,” in Heart Statistic 2008., pp. 1–52, The Danish Heart Foundation, 2008.
[2]
J. H. Pope and H. P. Selker, “Diagnosis of acute cardiac ischemia,” Emergency Medicine Clinics of North America, vol. 21, no. 1, pp. 27–59, 2003.
[3]
“Indications for fibrinolytic therapy in suspected acute myocardial infarction: collaborative overview of early mortality and major morbidity results from all randomised trials of more than 1000 patientsFibrinolytic Therapy Trialists' (FTT) Collaborative Group,” The Lancet, vol. 343, no. 8893, pp. 311–322, 1994.
[4]
G. De Luca, H. Suryapranata, J. P. Ottervanger, and E. M. Antman, “Time delay to treatment and mortality in primary angioplasty for acute myocardial infarction: every minute of delay counts,” Circulation, vol. 109, no. 10, pp. 1223–1225, 2004.
[5]
U. Zeymer, H. R. Arntz, B. Dirks et al., “Reperfusion rate and inhospital mortality of patients with ST segment elevation myocardial infarction diagnosed already in the prehospital phase: results of the German Prehospital Myocardial Infarction Registry (PREMIR),” Resuscitation, vol. 80, no. 4, pp. 402–406, 2009.
[6]
J. A. Feldman, K. Brinsfield, S. Bernard, D. White, and T. MacIejko, “Real-time paramedic compared with blinded physician identification of ST-segment elevation myocardial infarction: results of an observational study,” American Journal of Emergency Medicine, vol. 23, no. 4, pp. 443–448, 2005.
[7]
A. W. J. van 't Hof, S. Rasoul, H. van de Wetering et al., “Feasibility and benefit of prehospital diagnosis, triage, and therapy by paramedics only in patients who are candidates for primary angioplasty for acute myocardial infarction,” American Heart Journal, vol. 151, no. 6, pp. 1255.e1–1255.e5, 2006.
[8]
C. P. Holler, S. Wichmann, S. L. Nielsen, and A. M. M？ller, “Large discrepancy between prehospital visitation to mobile emergency care unit and discharge diagnosis,” Danish Medical Journal, vol. 59, no. 4, article 4415, 2012.
[9]
J. H. Pope, R. Ruthazer, J. R. Beshansky, J. L. Griffith, and H. P. Selker, “Clinical features of emergency department patients presenting with symptoms suggestive of acute cardiac ischemia: a multicenter study,” Journal of Thrombosis and Thrombolysis, vol. 6, no. 1, pp. 63–74, 1998.
[10]
R. Bruyninckx, B. Aertgeerts, P. Bruyninckx, and F. Buntinx, “Signs and symptoms in diagnosing acute myocardial infarction and acute coronary syndrome: a diagnostic meta-analysis,” British Journal of General Practice, vol. 58, no. 547, pp. 105–111, 2008.
[11]
S. W. Goodacre, K. Angelini, J. Arnold, S. Revill, and F. Morris, “Clinical predictors of acute coronary syndromes in patients with undifferentiated chest pain,” Quarterly Journal of Medicine, vol. 96, no. 12, pp. 893–898, 2003.
[12]
R. Body, S. Carley, C. Wibberley, G. McDowell, J. Ferguson, and K. Mackway-Jones, “The value of symptoms and signs in the emergent diagnosis of acute coronary syndromes,” Resuscitation, vol. 81, no. 3, pp. 281–286, 2010.
[13]
H. R. Arntz, L. L. Bossaert, N. Danchin, and N. I. Nikolaou, “European resuscitation council guidelines for resuscitation 2010 section 5. Initial management of acute coronary syndromes,” Resuscitation, vol. 81, no. 10, pp. 1353–1363, 2010.
[14]
J. Breckwoldt, D. Müller, M. Overbeck, R. Stern, L. Schnitzer, and H. R. Arntz, “Prehospital care of acute coronary syndrome by anaesthetists. Prospective comparison with the care standards of cardiologists,” Anaesthesist, vol. 57, no. 2, pp. 131–138, 2008.
[15]
J. K. Z. Hemsey, K. Dracup, K. Fleischmann, C. E. Sommargren, and B. J. Drew, “Prehospital 12-lead ST-segment monitoring improves the early diagnosis of acute coronary syndrome,” Journal of Electrocardiology, vol. 45, no. 3, pp. 266–271, 2012.
[16]
C. Lenfant, “Chest pain of cardiac and noncardiac origin,” Metabolism, vol. 59, Supplement 1, pp. S41–S46, 2010.
