Frank Breuckmann1, Matthias Hochadel2, Harald Darius3, Evangelos Giannitsis4, Thomas Münzel5, Lars S Maier6, Claus Schmitt7, Burghard Schumacher8, Gerd Heusch9, Thomas Voigtländer10, Harald Mudra11, Jochen Senges2. 1. Department of Cardiology, Arnsberg Medical Center, Arnsberg, Germany. Electronic address: f.breuckmann@klinikum-arnsberg.de. 2. Institute for Myocardial Infarction Research Foundation Ludwigshafen, University of Heidelberg, Heidelberg, Germany. 3. Department of Cardiology, Angiology and Intensive Care Medicine, Vivantes-Klinikum Neukölln, Berlin, Germany. 4. 3rd Department of Medicine, University Hospital Heidelberg, Heidelberg, Germany. 5. 2nd Department of Medicine, Johannes Gutenberg-University Mainz, Mainz, Germany. 6. Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany. 7. Clinic for Cardiology and Angiology, Municipal Hospital Karlsruhe, Karlsruhe, Germany. 8. 2nd Department of Medicine, Westpfalz-Klinikum, Kaiserslautern, Germany. 9. Institute for Pathophysiology, University Duisburg-Essen, Essen, Germany. 10. CCB, Cardioangiologisches Centrum Bethanien, Frankfurt am Main, Germany. 11. Department of Cardiology, Pneumology and Internal Intensive Care Medicine, Klinikum Neuperlach, Städtisches Klinikum München GmbH, Munich, Germany.
Abstract
BACKGROUND: We investigated the current management of unstable angina pectoris (UAP) in certified chest pain units (CPUs) in Germany and focused on the European Society of Cardiology (ESC) guideline-adherence in the timing of invasive strategies or choice of conservative treatment options. More specifically, we analyzed differences in clinical outcome with respect to guideline-adherence. METHOD: Prospective data from 1400 UAP patients were collected. Analyses of high-risk criteria with indication for invasive management and 3-month clinical outcome data were performed. Guideline-adherence was tested for a primarily conservative strategy as well as for percutaneous coronary intervention (PCI) within <24 and <72h after admission. RESULTS: Overall guideline-conforming management was performed in 38.2%. In UAP patients at risk, undertreatment caused by an insufficient consideration of risk criteria was obvious in 78%. Reciprocally, overtreatment in the absence of adequate risk markers was performed in 27%, whereas a guideline-conforming primarily conservative strategy was chosen in 73% of the low-risk patients. Together, the 3-month major adverse coronary and cerebrovascular events (MACCE) were low (3.6%). Nonetheless, guideline-conforming treatment was even associated with significantly lower MACCE rates (1.6% vs. 4.0%, p<0.05). CONCLUSION: The data suggest an inadequate adherence to ESC guidelines in nearly two thirds of the patients, particularly in those patients at high to intermediate risk with secondary risk factors, emphasizing the need for further attention to consistent risk profiling in the CPU and its certification process.
BACKGROUND: We investigated the current management of unstable angina pectoris (UAP) in certified chest pain units (CPUs) in Germany and focused on the European Society of Cardiology (ESC) guideline-adherence in the timing of invasive strategies or choice of conservative treatment options. More specifically, we analyzed differences in clinical outcome with respect to guideline-adherence. METHOD: Prospective data from 1400 UAP patients were collected. Analyses of high-risk criteria with indication for invasive management and 3-month clinical outcome data were performed. Guideline-adherence was tested for a primarily conservative strategy as well as for percutaneous coronary intervention (PCI) within <24 and <72h after admission. RESULTS: Overall guideline-conforming management was performed in 38.2%. In UAP patients at risk, undertreatment caused by an insufficient consideration of risk criteria was obvious in 78%. Reciprocally, overtreatment in the absence of adequate risk markers was performed in 27%, whereas a guideline-conforming primarily conservative strategy was chosen in 73% of the low-risk patients. Together, the 3-month major adverse coronary and cerebrovascular events (MACCE) were low (3.6%). Nonetheless, guideline-conforming treatment was even associated with significantly lower MACCE rates (1.6% vs. 4.0%, p<0.05). CONCLUSION: The data suggest an inadequate adherence to ESC guidelines in nearly two thirds of the patients, particularly in those patients at high to intermediate risk with secondary risk factors, emphasizing the need for further attention to consistent risk profiling in the CPU and its certification process.
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