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8th November 2021
Acute coronary syndrome (ACS) presentations using emergency medical services increased after the introduction of a public health ‘warning signs’ campaign. This was the finding of a retrospective study by researchers from the department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.
Any delay in ACS presentations has a major impact on outcomes for patients, despite major advances in the care of such patients yet few fully understand the importance of early treatment. For example, a focus group study revealed a general ignorance of ACS symptoms and this has arisen in part, due to the perceptions derived from films and TV in which heart attack symptoms were displayed as sharp, crushing chest pain rather than the more common onset of initially ambiguous but gradually increasing discomfort. The study also highlighted a lack of awareness of the benefits of rapid action and using emergency service transport (EST) to hospital over alternative methods for reaching hospital. In fact, other work has shown that only 60% of patients used EST when experiencing ST-segment–elevation myocardial infarction.
The National Heart Foundation of Australia (NHFA) in recognising the importance of EST for patients with suspected ACS, launched a mass media campaign to improve Australian’s ACS symptom knowledge and address barriers to emergency transport use. Nevertheless, despite the media campaign, in a subsequent survey of 100 patients hospitalised with an acute myocardial infarction (AMI) only 26% recognised that they were having an AMI and only 34% had called an ambulance. This led the researchers from Monash University to examine the impact of the NHFA warning signs campaign on ACS EST use and to explore any pre- and post-campaign changes on ED presentations via general practitioners for those with unspecified chest pain (U-CP). The team used the Victorian Department of Health and Human Services administrative database to collect information of ED admissions, patient characteristics, mode of arrival and referral sources. The primary outcomes of interest were ACS arrivals via ETS and ED presentations. Data were collected from 2003 to 2015, that included the period of the campaign which ran from 2009 to 2013. In their analysis, the researchers adjusted for factors such as age, gender, ethnicity, residential status (i.e., living alone etc) and location.
Between 2003 and 2015, there were 124,632 eligible ED presentations with ACS and 612,758 with U-CP. There was an 11% increase in ED presentations for ACS (incidence rate ratio, IRR = 1.11, 95% CI 1.07 – 1.15) during the campaign compared to the pre-campaign period. Similarly, there was an 8% increase (IRR = 1.08, 95% CI 1.05 – 1.12) for U-CP compared to the pre-campaign period.
For patients with ACS, 58% had arrived using emergency transport and compared with the pre-campaign period there was a slight increase in the adjusted odds of direct arrival via emergency transport (odds ratio, OR = 1.10, 95% CI 1.05 – 1.17) and a significant decrease in the adjusted odds of a GP referral (OR = 0.77, 95% CI 0.70 to 0.86). For U-CP, there was a modest increase during the campaign period of emergency transport arrivals (OR = 1.03, p = 0.019) but a more substantial reduction in GP referral compared to pre-campaign levels (OR = 0.79, 96% CI 0.75 – 0.82, p < 0.0001).
The authors concluded that the NHFA’s warning signs campaign was associated with an increase in ACS presentations and use of emergency transport and a reduction in GP referrals to ED.
Eastwood K et al. Impact of a mass media campaign on presentations and ambulance use for acute coronary syndrome. BMJ Open heart 2021
4th October 2021
Acute chest pain is a common reason for attendance at an emergency department, accounting for approximately 10% of non-injury-related visits. While chest pain can arise from non-cardiac causes, all those presenting with chest pain will be assessed for acute coronary syndrome (ACS). Prompt treatment is required for patients with obvious clinical signs and symptoms of ACS whereas those deemed to be at either a low or intermediate risk initially undergo observation and further testing only if ACS is suspected. One strategic approach to the assessment of low risk ACS patients, is early computed tomography (CT) coronary angiography (CTCA). This technique has been increasingly used to assess patients with stable chest pain because it has high sensitivity and specificity for the detection of coronary heart disease. Within an emergency care department, CTCA therefore allows for a rapid evaluation of patients presenting with acute chest pain. In fact, one systematic review concluded that the use of CTCA is associated with a reduced length of hospital stay compared to usual care. Furthermore, a 2018 study examining the use of CTCA in patients with stable chest pain, found that over a 5-year period, there was a significantly lower rate of death from coronary heart disease or non-fatal myocardial infarction compared to standard care. However, while studies have focused on patients at low risk of ACS, whether early CTCA is of value in those patients deemed to be at an intermediate risk of ACS is less clear.
In trying to assess the value of early CTCA in patients presenting with acute chest pain and at an intermediate level of risk for acute coronary syndrome, researchers from Edinburgh University, established the RAPID CTCA study. The trial enrolled adult patients with suspected or a provisional diagnosis, of acute coronary syndrome and prior coronary heart disease. These individuals where then randomised 1:1 after admission to hospital to early CT coronary angiography with standard care or standard care alone. The primary outcome was the time to the first event of all-cause death or a subsequent non-fatal type 1 (spontaneous) or type 4b (related to stent thrombosis) myocardial infarction at one-year. Secondary outcomes included the cause of death and subsequent myocardial infarction.
The study recruited and randomised 1748 patients with a mean age of 61.6 years (64% men), of whom 877 received early CTCA. Overall, 89% of patients had chest pain as their primary complaint, 34% had existing coronary heart disease, 57% raised cardiac troponin levels and 61% an abnormal ECG. The primary outcome all cause death or non-fatal myocardial infarction (both types) occurred in 5.8% of those in the early CTCA group and 6.1% of those assigned to usual care (adjusted hazard ratio, aHR = 0.91, 95% CI 0.62 – 1.35, p = 0.65). Furthermore, there were no significant differences in any of the secondary outcomes. The need for invasive coronary angiography occurred in 54% of those in the CTCA group and 60.8% in the usual care group (aHR = 0.81, 95% CI 0.72 – 0.92, p = 0.001).
The authors concluded that early CTCA for patients with an intermediate risk of ACS did not alter overall coronary therapeutic interventions or one year clinical outcomes but did reduce the need for invasive angiography.