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Chest pain and ischemic heart disease: Diagnosis and management in primary health care
Linköping University, Department of Medicine and Health Sciences. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in the East of Östergötland, East County Primary Health Care.
2008 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background and aims. In patients consulting for chest pain, it is of great importance to evaluate the possibility of ischemic heart disease (IHD). The aims in this thesis were to investigate the accuracy of the general practitioners’ clinical assessments and the applicability of exercise testing and myocardial perfusion scintigraphy (MPS) in patients consulting for chest pain in primary care.

Statins are known to prevent IHD. A further aim was therefore to investigate if a relation could be detected on a population basis between the use of statins and the morbidity of acute myocardial infarction (AMI).

Methods. All patients from 20 to 79 years, consulting for a new episode of chest pain in three primary health care centres, were included during almost two years from 1998 to 2000. The patients were managed according to the clinical evaluation. The presence of IHD was excluded either by clinical examination only, or if stable IHD was in question, by exercise testing and if the exercise test was inconclusive by an additional MPS. If unstable IHD or myocardial infarction was suspected, referral for emergency hospital examination was made.

Correlations between statin sales and the morbidity of AMI in Sweden’s municipalities were analysed in an ecological, register based study. Adjustment was made for sales of antidiabetics, socio-economic deprivation indexes and geographic coordinates.

Results. Consultations for chest pain represented 1.5% of all consultations in the ages 20 to 79 and were made by 554 patients. In 281 patients IHD was excluded by clinical examination only. In 208 patients stable IHD and in 65 unstable IHD was in question. Four patients (1.4%) evaluated as not having IHD, were diagnosed with angina pectoris or AMI within three months. Exercise testing was performed in 191 patients and revealed no IHD in 134 and IHD in 14 patients. In 43 patients the exercise test results were equivocal. Thirty-nine of these patients underwent MPS, which showed no IHD in 20 and IHD in 19 of the patients.

In a follow up almost six years later, neither mortality rate nor prevalence of IHD differed significantly between the 384 study patients evaluated not to have IHD and the population controls.

Statin sales and AMI-incidence or mortality showed no strong associations from 1998 to 2002.

Conclusions.

·Primary care is an appropriate level of care for ruling out IHD as the cause of chest pain, with sufficient safety and for diagnostics of stable IHD.

·Exercise testing and myocardial perfusion scintigraphy are useful procedures when investigating chest pain patients in primary care.

·The results indicate that preventive measures other than increased statin treatment should be considered to further decrease AMI-morbidity.

Place, publisher, year, edition, pages
Institutionen för medicin och hälsa , 2008. , 253 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1039
Keyword [en]
Chest pain, ischemic heart disease, primary health care, diagnosis, lipid lowering drugs
National Category
Clinical Science
Identifiers
URN: urn:nbn:se:liu:diva-11390ISBN: 978-91-7393-987-4 (print)OAI: oai:DiVA.org:liu-11390DiVA: diva2:17797
Public defence
2008-04-11, Aulan, Hälsans Hus, Campus US, Linköpings universitet, Linköping, 09:00 (English)
Opponent
Supervisors
Available from: 2008-03-25 Created: 2008-03-25 Last updated: 2009-08-21
List of papers
1. Chest pain and ischaemic heart disease in primary care
Open this publication in new window or tab >>Chest pain and ischaemic heart disease in primary care
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2003 (English)In: British Journal of General Practice, ISSN 0960-1643, Vol. 53, no 490, 378-382 p.Article in journal (Refereed) Published
Abstract [en]

Background: Chest pain is the main symptom of first presentation with ischaemic heart disease (IHD). Little is known about the incidence of IHD among patients consulting the general practitioner (GP) for chest pain.

Aims: To estimate the occurrence of IHD among patients consulting for chest pain, to study the results of the bicycle exercise test, and to estimate the incidence of IHD in the population.

Design of study: Prospective descriptive study.

Setting: Three primary health centres in south-eastern Sweden

Method: All patients without a current IHD diagnosis, aged 20 to 79 years, and consulting for a new episode of chest pain, were included consecutively. The outcome was classified as IHD, possible IHD or not IHD, according to the results of a postal questionnaire, an exercise test or hospital care. Data from the hospital registry on patients with a diagnosis of IHD were analysed retrospectively.

Results: Out of 38 075 GP consultations, 577 (1.5%) were for chest pain. IHD was diagnosed in 41 (8%) of the chest pain patients, in 41 (83%) the diagnosis was excluded, and in 50 (9%) the diagnosis was judged as being uncertain. Even though the diagnostic criteria were strict, the exercise tests led to a diagnostic conclusion in 77% of the cases, most frequently a normal test result. Combining data from primary and hospital care, the yearly incidence of IHD was 6.5 diagnosed per 1000 inhabitants (aged 20 to 79 years old).

Conclusion: The incidence of a new episode of chest pain bringing the patient to the GP was low. Eight per cent of the patients received an IHD diagnosis, and in 9% further investigation or clinical assessment is needed.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-13082 (URN)
Available from: 2008-03-25 Created: 2008-03-25 Last updated: 2009-08-20
2. Exercise testing and myocardial perfusion scintigraphy in primary care patients with chest pain of new onset
Open this publication in new window or tab >>Exercise testing and myocardial perfusion scintigraphy in primary care patients with chest pain of new onset
2007 (English)In: Scandinavian Journal of Primary Health Care, ISSN 0281-3432, E-ISSN 1502-7724, Vol. 25, no 2, 117-122 p.Article in journal (Refereed) Published
Abstract [en]

Objective: To analyse the outcome of exercise testing and myocardial perfusion scintigraphy (MPS) in primary care patients with chest pain of new onset.

Design: Prospective, observational. Patients aged 20-79 years, consulting due to chest pain of new onset, were enrolled consecutively.

Setting: Three primary care health centres in south-eastern Sweden.

Patients: 191 patients where the possibility of stable ischaemic heart disease (IHD) could not be excluded by clinical examination alone.

Main outcome measures: Exercise test results, when equivocal completed by MPS.

Results: Exercise testing revealed IHD in 14 (7%) and no IHD in 134 (70%) of the cases. In 43 (23%) the exercise test results were equivocal. Thirty-nine of these patients underwent MPS, which showed IHD in 19 and no IHD in 20 cases. Among previously diagnosed cardiovascular disease and risk factors only atrial fibrillation in the male group showed a significant correlation to the outcome IHD.

Conclusion: Exercise testing and MPS are both useful when investigating chest pain patients in primary care.

Keyword
Chest pain, exercise test, family practice, myocardial ischaemia, myocardial perfusion imaging, primary healthcare, risk factors
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-13083 (URN)10.1080/02813430601116249 (DOI)
Available from: 2008-03-25 Created: 2008-03-25 Last updated: 2014-01-10
3. The accuracy of general practitioners' clinical assessment of chest pain patients
Open this publication in new window or tab >>The accuracy of general practitioners' clinical assessment of chest pain patients
2008 (English)In: European Journal of General Practice, ISSN 1381-4788, E-ISSN 1751-1402, Vol. 14, no 2, 50-55 p.Article in journal (Refereed) Published
Abstract [en]

Objective: To study general practitioners' (GP) assessment of the probability of ischaemic heart disease (IHD) and GP action in daily practice regarding chest pain patients.

Methods: All chest pain patients aged 20-79 years, attending three primary health-care centres in south-east Sweden and assessed by the GP to have high, low or very low probability of IHD, were included consecutively over a two year period. The “GP action in daily practice” was classed as “active decisions” (investigation or treatment) or “wait and see”. “IHD” or “not IHD” was settled according to the results of acute hospital investigation or exercise testing/myocardial perfusion scintigraphy.

Results: 516 patients were included, 93 high, 145 low and 278 very low probability cases. The outcome was “IHD” in 47%, 9% and 1% respectively. The sensitivity and specificity of the “GP assessment of the probability of IHD” were 72% and 89%. The sensitivity and specificity of the “GP action in daily practice” were 88% and 72%, respectively. The negative predictive value was 98%.

Conclusion: GP assessment, after clinical evaluation, that the probability of IHD was low did not safely rule out IHD. GP action in daily practice however, indicates that general practice is an appropriate level of care for chest pain patients.

Keyword
Chest Pain, Primary Health-care, Myocardial Ischaemia, Decision Making
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-13084 (URN)10.1080/13814780802342622 (DOI)
Available from: 2008-03-25 Created: 2008-03-25 Last updated: 2013-04-05
4. No connection between the level of exposition to statins in the population and the incidence/mortality of acute myocardial infarction: An ecological study based on Sweden’s municipalities
Open this publication in new window or tab >>No connection between the level of exposition to statins in the population and the incidence/mortality of acute myocardial infarction: An ecological study based on Sweden’s municipalities
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2011 (English)In: Journal of Negative Results in Biomedicine, ISSN 1477-5751, E-ISSN 1475-9306, Vol. 10, no 6Article in journal (Refereed) Published
Abstract [en]

Background

Randomised controlled trials have shown an excellent preventive effect of statins on ischemic heart disease. Our objective was to investigate if a relation can be detected between acute myocardial infarction- (AMI) mortality or incidence and statin utilisation, for men and women in different age-groups on a population basis.

Results

The utilisation rate of statins increased almost three times for both men and women between 1998 and 2002. During 1998-2000 the incidence of AMI decreased clearly for men but only slightly for women. Mortality decreased from 1998 to 2002. The change in statin utilisation from 1998 to 2000 showed no correlation to the change in AMI mortality from 2000 to 2002. Statin utilisation and AMI- incidence or mortality showed no correlations when adjusting for socio-economic deprivation, antidiabetic drugs and geographic coordinates.

Conclusions

Despite a widespread and increasing utilisation of statins, no correlation to the incidence or mortality of AMI could be detected. Other factors than increased statin treatment should be analysed especially when discussing the allocation of public resources.

Keyword
Myocardial infarction, Incidence, Antilipemic agents, Sweden; Population, Ecological study
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-13085 (URN)10.1186/1477-5751-10-6 (DOI)
Note

On the day of the defence day the status of this article was: Submitted

Available from: 2008-03-25 Created: 2008-03-25 Last updated: 2014-09-23

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