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. 2022 Dec;47(6):543-552.
doi: 10.1007/s00059-021-05079-2. Epub 2021 Nov 9.

Survey of clinical practice pattern in Germany's certified chest pain units : Adherence to the European Society of Cardiology guidelines on non-ST-segment elevation acute coronary syndrome

Frank Breuckmann  1 , Stephan Settelmeier  2 , Tienush Rassaf  2 , Felix Post  3 , Winfried Haerer  4 , Johann Bauersachs  5 , Harald Mudra  6 , Thomas Voigtländer  7 , Jochen Senges  8 , Thomas Münzel  9 , Evangelos Giannitsis  10
Affiliations

Survey of clinical practice pattern in Germany's certified chest pain units : Adherence to the European Society of Cardiology guidelines on non-ST-segment elevation acute coronary syndrome

Frank Breuckmann et al. Herz. 2022 Dec.

Abstract
in English, German

Background: We aimed to analyze the 2020 standard of care in certified German chest pain units (CPU) with a special focus on non-ST-segment elevation acute coronary syndrome (NSTE-ACS) through a voluntary survey obtained from all certified units, using a prespecified questionnaire.

Methods: The assessment included the collection of information on diagnostic protocols, risk assessment, management and treatment strategies in suspected NSTE-ACS, the timing of invasive therapy in non-ST-segment elevation myocardial infarction (NSTEMI), and the choice of antiplatelet therapy.

Results: The response rate was 75%. Among all CPUs, 77% are currently using the European Society of Cardiology (ESC) 0/3‑h high-sensitive troponin protocol, and only 20% use the ESC 0/1‑h high-sensitive troponin protocol as a default strategy. Conventional ergometry is still the commonly performed stress test with a utilization rate of 47%. Among NSTEMI patients, coronary angiography is planned within 24 h in 96% of all CPUs, irrespective of the day of the week. Prasugrel is the P2Y12 inhibitor of choice in ST-segment elevation myocardial infarction (STEMI), but despite the impact of the ISAR-REACT 5 trial on selection of antiplatelet therapy, ticagrelor is still favored over prasugrel in NSTE-ACS. If triple therapy is used in NSTE-ACS with atrial fibrillation, it is maintained up to 4 weeks in 51% of these patients.

Conclusion: This survey provides evidence that Germany's certified CPUs ensure a high level of guideline adherence and quality of care. The survey also identified areas in need of improvement such as the high utilization rate of stress electrocardiogram (ECG).

Zusammenfassung: HINTERGRUND: Ziel der Arbeit war eine Versorgungsanalyse für das Jahr 2020 im Hinblick auf das akute Koronarsyndrom ohne ST-Strecken-Hebung (NSTE-ACS), welche anhand eines standardisierten Fragebogens in allen zertifizierten Brustschmerzeinheiten (CPU) in Deutschland durchgeführt wurde.

Methoden: In die Bewertung flossen Diagnoseprotokolle, Risikobewertung, Management- und Behandlungsstrategien bei Verdacht auf NSTE-ACS, Zeitpunkt der invasiven Therapie beim Nicht-ST-Strecken-Hebungs-Myokardinfarkt (NSTEMI) und die Wahl der Thrombozytenaggregationshemmung ein.

Ergebnisse: Die Rücklaufquote betrug 75 %. Von allen CPU verwenden derzeit 77 % das ESC 0/3-h-high-sensitive-Troponin-Protokoll, und nur 20 % haben das ESC 0/1-h-high-sensitive-Troponin-Protokoll als Standardstrategie. Die konventionelle Ergometrie ist mit einer Durchführungsrate von 47 % nach wie vor der am häufigsten durchgeführte Belastungstest. Bei NSTEMI-Patienten wird in 96 % aller CPU, unabhängig vom Wochentag, eine Koronarangiographie innerhalb von 24 h geplant. Prasugrel ist der P2Y12-Inhibitor der Wahl beim ST-Strecken-Hebungs-Myokardinfarkt. Trotz der Ergebnisse der ISAR-REACT-5-Studie wird Ticagrelor beim NSTE-ACS immer noch gegenüber Prasugrel bevorzugt. Wird eine Tripeltherapie beim NSTE-ACS mit Vorhofflimmern eingeleitet, wird diese in 51 % der CPU bis zu 4 Wochen empfohlen.

Schlussfolgerung: Die vorliegende repräsentative Umfrage unter den zertifizierten CPU liefert Belege für ein hohes Maß an Leitlinienkonformität und Versorgungsqualität in diesen Einheiten. Die Analyse deckt jedoch auch Bereiche mit Verbesserungsbedarf (wie die unverändert hohe Rate an Belastungs-EKG) auf.

Keywords: Antiplatelet therapy; PCI; Standard of care; Timing; Troponin protocol.

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Conflict of interest statement

F. Breuckmann, S. Settelmeier, T. Rassaf, F. Post, W. Haerer, J. Bauersachs, H. Mudra, T. Voigtländer, J. Senges, T. Münzel and E. Giannitsis declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Different use of high-sensitive troponin protocols in certified German chest pain units in total (a) and in a subanalysis for the 0/1‑h protocol by facility type (b)
Fig. 2
Fig. 2
Direct-invasive vs. primarily noninvasive diagnostic approaches (a) and stress testing of choice (b) in troponin-negative non-ST-segment elevation acute coronary syndrome
Fig. 3
Fig. 3
Timing of invasive therapy in patients with non-ST-segment elevation acute coronary syndrome (NSTE-ACS) at very high risk (a) or in troponin-positive NSTE-ACS patients without criteria of urgent invasive management (b); 11% of CPUs stated that invasive diagnostics are often postponed to the next Monday (c)
Fig. 4
Fig. 4
Prasugrel administration in ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI) patients dependent on hospital type and geographical allocation
Fig. 5
Fig. 5
Default set of duration of triple therapy in patients with acute coronary syndrome and atrial fibrillation (m months, d days)
See this image and copyright information in PMC

References

    1. German Cardiac Society (2017) Certification as a chest pain unit. https://cpu.dgk.org. Accessed 1 Apr 2020
    1. Varnavas V, Rassaf T, Breuckmann F. Nationwide but still inhomogeneous distribution of certified chest pain units across Germany: need to strengthen rural regions. Herz. 2018;43(1):78–86. doi: 10.1007/s00059-016-4527-0. - DOI - PubMed
    1. Breuckmann F, Post F, Giannitsis E, et al. Kriterien der Deutschen Gesellschaft für Kardiologie – Herz- und Kreislaufforschung für „Chest-Pain-Units“. Kardiologe. 2008;2(5):389–394. doi: 10.1007/s12181-008-0116-7. - DOI
    1. Post F, Gori T, Giannitsis E, et al. Criteria of the German Society of Cardiology for the establishment of chest pain units: update 2014. Clin Res Cardiol. 2015;104(11):918–928. doi: 10.1007/s00392-015-0888-2. - DOI - PMC - PubMed
    1. Giannitsis E, Post F, Haerer W, et al. Kriterien der Deutschen Gesellschaft für Kardiologie – Herz- und Kreislaufforschung für „Chest Pain Units“: Update 2020. Kardiologe. 2020 doi: 10.1007/s12181-020-00417-w. - DOI

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