Improvements in acute coronary syndrome diagnosis: Focus on pre-hospital management

Abstract

Acute coronary syndrome (ACS) is a life threatening disease that requires short treatment delays to reduce complications. International Cardiac guidelines have specific recommendations about the delays in ACS patients. To decrease the treatment delays and achieve the guideline recommendations, many researchers in the past have focussed on in-hospital delays, neglecting the pre-hospital delays. This dissertation focusses on the pre-hospital delay and the network of ACS patients. In part I of this dissertation we review interventions that aim to shorten the pre-hospital delays of ST-elevated myocardial infarction (STEMI) patients, a specific group within ACS patients that benefit the most from a short treatment delay. These interventions include the start of an off-site percutaneous coronary intervention (PCI) centre, a PCI centre without in-hospital surgical back-up, and the start of an ACS focus group involving all (para-)medics within the ACS network. We show that the treatment of STEMI patients at an off-site PCI centre is safe and effective. The guideline advised goals in STEMI patients can be achieved through the start of an off-site PCI centre and an ACS focus group. Referring all chest pain patients without restriction to the emergency department to reduce pre-hospital delays and achieve guideline recommendations is not feasible. Chest pain is a common symptom and non-cardiac chest pain (NCCP) is diagnosed in up to 80% of patients referred to the emergency department. In part II we analyse the scope of the NCCP referrals. We show that there is a need for tools in the pre-hospital triage of chest pain patients, due to the difficulty of differentiating between ACS and non-ACS patients without additional testing. While the prognosis of NCCP patients exceeds that of cardiac chest pain patients they utilize substantial medical resources at the Cardiology Department. We analysed the use of the HEART score in the pre-hospital setting, a risk score incorporating an electrocardiogram and troponin testing. This showed promising results but also the need for a fast and reliable point-of-care troponin tester to incorporate into the risk score.