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Aim: The purpose of this work was to analyze structure, distribution, and bed capacities of certified German chest pain units (CPUs) to unveil potential gaps despite nationwide certification of 230 units till the end of 2015.Methods: Analysis of number and structure of CPUs per state, resident count, and population density by standardized telephone interview, online research, and data collection from the registry of the Federal Statistical Office for all certified German CPUs.Results: Nationwide, German health facilities provided a mean of 1 CPU bed within a certified unit per 65,000 inhabitants. Bremen, Hamburg, Hesse, and Rhineland-Palatinate provided more than 1 bed per 50,000 inhabitants. Most CPUs (49%) were located in the emergency room. All university hospitals in Germany provided a certified CPU. Most units were found in academic teaching hospitals (146 CPUs). Only 42 CPUs were found in nonacademic providers of primary health care.Conclusion: The absolute necessary number of CPUs to reach full nationwide coverage is still unknown. The current analysis shows a high number of CPUs and bed capacities within the cities and industrial areas without relevant gaps, but also demonstrates a certain undersupply in more rural areas as well as in some of the former eastern federal states of Germany. [ABSTRACT FROM AUTHOR]

Background: Current guidelines emphasize the diagnostic value of non-cardiac or possibly cardiac chest pain. The goal of this analysis was to determine whether German chest pain units (CPUs) adequately address conditions with "atypical" chest pain in existing diagnostic structures., Method: A total of 11,734 patients from the German CPU registry were included. The analyses included mode of admission, critical time intervals, diagnostic steps, and differential diagnoses., Results: Patients with unspecified chest pain were younger, more often female, were less likely to have classic cardiovascular risk factors and tended to present more often as self-referrals. Patients with acute coronary syndrome (ACS) mostly had prehospital medical contact. Overall, there was no difference between these two groups regarding the time from the onset of first symptoms to arrival at the CPU. In the CPU, the usual basic diagnostic measures were performed irrespective of ACS as the primary working diagnosis. In the non-ACS group, further ischemia-specific diagnostics were rarely performed. Extra-cardiac differential diagnoses were not specified., Conclusion: The establishment of broader awareness programs and opening CPUs for low-threshold evaluation of self-referring patients should be discussed. Regarding the rigid focus on the clarification of cardiac causes of chest pain, a stronger interdisciplinary approach should be promoted., (© 2023. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Chest pain poses a diagnostic challenge in the emergency department and requires a thorough clinical assessment. The traditional distinction between "atypical" and "typical" chest pain carries the risk of not addressing nonischemic clinical pictures. The newly conceived subdivision into cardiac, possibly cardiac, and (probably) noncardiac causes of the presenting symptom complex addresses a much more interdisciplinary approach to a symptom-oriented diagnostic algorithm. The diagnostic structures of the chest pain units in Germany do not currently reflect this. An adaptation should therefore be considered., (© 2024. The Author(s), under exclusive licence to Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: ChatGPT is a 175-billion-parameter natural language processing model that is already involved in scientific content and publications. Its influence ranges from providing quick access to information on medical topics, assisting in generating medical and scientific articles and papers, performing medical data analyses, and even interpreting complex data sets., Objective: The future role of ChatGPT remains uncertain and a matter of debate already shortly after its release. This review aimed to analyze the role of ChatGPT in the medical literature during the first 3 months after its release., Methods: We performed a concise review of literature published in PubMed from December 1, 2022, to March 31, 2023. To find all publications related to ChatGPT or considering ChatGPT, the search term was kept simple ("ChatGPT" in AllFields). All publications available as full text in German or English were included. All accessible publications were evaluated according to specifications by the author team (eg, impact factor, publication modus, article type, publication speed, and type of ChatGPT integration or content). The conclusions of the articles were used for later SWOT (strengths, weaknesses, opportunities, and threats) analysis. All data were analyzed on a descriptive basis., Results: Of 178 studies in total, 160 met the inclusion criteria and were evaluated. The average impact factor was 4.423 (range 0-96.216), and the average publication speed was 16 (range 0-83) days. Among the articles, there were 77 editorials (48,1%), 43 essays (26.9%), 21 studies (13.1%), 6 reviews (3.8%), 6 case reports (3.8%), 6 news (3.8%), and 1 meta-analysis (0.6%). Of those, 54.4% (n=87) were published as open access, with 5% (n=8) provided on preprint servers. Over 400 quotes with information on strengths, weaknesses, opportunities, and threats were detected. By far, most (n=142, 34.8%) were related to weaknesses. ChatGPT excels in its ability to express ideas clearly and formulate general contexts comprehensibly. It performs so well that even experts in the field have difficulty identifying abstracts generated by ChatGPT. However, the time-limited scope and the need for corrections by experts were mentioned as weaknesses and threats of ChatGPT. Opportunities include assistance in formulating medical issues for nonnative English speakers, as well as the possibility of timely participation in the development of such artificial intelligence tools since it is in its early stages and can therefore still be influenced., Conclusions: Artificial intelligence tools such as ChatGPT are already part of the medical publishing landscape. Despite their apparent opportunities, policies and guidelines must be implemented to ensure benefits in education, clinical practice, and research and protect against threats such as scientific misconduct, plagiarism, and inaccuracy., (©Daniel Gödde, Sophia Nöhl, Carina Wolf, Yannick Rupert, Lukas Rimkus, Jan Ehlers, Frank Breuckmann, Timur Sellmann. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 16.11.2023.)

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)., (© 2021. The Author(s).)

Aims: Early heart attack awareness programs are thought to increase efficacy of chest pain units (CPU) by providing live-saving information to the community. We hypothesized that self-referral might be a feasible alternative to activation of emergency medical services (EMS) in selected chest pain patients with a specific low-risk profile., Methods and Results: In this observational registry-based study, data from 4743 CPU patients were analyzed for differences between those with or without severe or fatal prehospital or in-unit events (out-of-hospital cardiac arrest and/or in-unit death, resuscitation or ventricular tachycardia). In order to identify a low-risk subset in which early self-referral might be recommended to reduce prehospital critical time intervals, the Global Registry of Acute Coronary Events (GRACE) score for in-hospital mortality and a specific low-risk CPU score developed from the data by multivariate regression analysis were applied and corresponding event rates were calculated. Male gender, cardiac symptoms other than chest pain, first onset of symptoms and a history of myocardial infarction, heart failure or cardioverter defibrillator implantation increased propensity for critical events. Event rates within the low-risk subsets varied from 0.5-2.8%. Those patients with preinfarction angina experienced fewer events., Conclusions: When educating patients and the general population about angina pectoris symptoms and early admission, activation of EMS remains recommended. Even in patients without any CPU-specific risk factor, self-referral bears the risk of severe or fatal pre- or in-unit events of 0.6%. However, admission should not be delayed, and self-referral might be feasible in patients with previous symptoms of preinfarction angina., (© 2021. The Author(s).)

Background: Medical emergencies are complex and stressful, especially for the young and inexperienced. Cognitive aids (CA) have been shown to facilitate management of simulated medical emergencies by experienced teams. In this randomized trial we evaluated guideline adherence and treatment efficacy in simulated medical emergencies managed by residents with and without CA., Methods: Physicians attending educational courses executed simulated medical emergencies. Teams were randomly assigned to manage emergencies with or without CA. Primary outcome was risk reduction of essential working steps. Secondary outcomes included prior experience in emergency medicine and CA, perceptions of usefulness, clinical relevance, acceptability, and accuracy in CA selection. Participants were grouped as "medical" (internal medicine and neurology) and "perioperative" (anesthesia and surgery) regarding their specialty. The study was designed as a prospective randomized single-blind study that was approved by the ethical committee of the University Duisburg-Essen (19-8966-BO)., Trial Registration: DRKS, DRKS00024781. Registered 16 March 2021-Retrospectively registered, http://www.drks.de/DRKS00024781 ., Results: Eighty teams participated in 240 simulated medical emergencies. Cognitive aid usage led to 9% absolute and 15% relative risk reduction. Per protocol analysis showed 17% absolute and 28% relative risk reduction. Wrong CA were used in 4%. Cognitive aids were judged as helpful by 94% of the participants. Teams performed significantly better when emergency CA were available (p < 0.05 for successful completion of critical work steps). Stress reduction using CA was more likely in "medical" than in "perioperative" subspecialties (3.7 ± 1.2 vs. 2.9 ± 1.2, p < 0.05)., Conclusions: In a high-fidelity simulation study, CA usage was associated with significant reduction of incorrect working steps in medical emergencies management and was characterized by high acceptance. These findings suggest that CA for medical emergencies may have the potential to improve emergency care., (© 2022. The Author(s).)

Background: Little is known about importance and implementation of end-of-life care (EOLC) in German intensive care units (ICU). This survey analyses preferences and differences in training between "medical" (internal medicine, neurology) and "surgical" (surgery, anaesthesiology) residents during intensive care rotation., Methods: This is a point-prevalence study, in which intensive care medicine course participants of one educational course were surveyed. Physicians from multiple ICU and university as well as non-university hospitals and all care levels were asked to participate. The questionnaire was composed of a paper and an electronic part. Demographic and structural data were prompted and EOLC data (48 questions) were grouped into six categories considering importance and implementation: category 1 (important, always implemented), 2 (important, sometimes implemented), 3 (important, never implemented) and 4-6 (unimportant, implementation always, sometimes, never). The trial is registered at the "Deutsches Register für klinische Studien (DRKS)", Study number DRKS00026619, registered on September 10th 2021, www.drks.de ., Results: Overall, 194/ 220 (88%) participants responded. Mean age was 29.7 years, 55% were female and 60% had scant ICU working experience. There were 64% medical and 35% surgical residents. Level of care and size of ICU differed significantly between medical and surgical (both p < 0.001). Sufficient implementation was stated for 66% of EOLC questions, room for improvement (category 2 and 3) was seen in 25, and 8% were classified as irrelevant (category 6). Areas with the most potential for improvement included prognosis and outcome and patient autonomy. There were no significant differences between medical and surgical residents., Conclusions: Even though EOLC is predominantly regarded as sufficiently implemented in German ICU of all specialties, our survey unveiled still 25% room for improvement for medical as well as surgical ICU residents. This is important, as areas of improvement potential may be addressed with reasonable effort, like individualizing EOLC procedures or setting up EOLC teams. Health care providers as well as medical societies should emphasize EOLC training in their curricula., (© 2022. The Author(s).)

Background: Chest pain units (CPU) and stroke units (SU) have both become established as essential components of clinical emergency care. For both instances dedicated certification processes are installed. Up to summer 2020, 290 CPUs and 335 SUs have been successfully certified., Objective: The aim of this review is to compare the structures and the current certification situation of CPUs and SUs. Also, the younger CPU certification process is compared to the long established SU certification standard., Material Und Methods: The comparison includes the historical background, the certification process, quality benchmarking, possible additive structures, the current status of certification in Germany, the transfer of the concept to the European level as well as reimbursement issues., Results: Both certification concepts show clear analogies. Evidence for SUs is supported by a positive Cochrane analysis and for CPUs there are many studies from the German CPU registry. The main differences include a uniform CPU system versus a multistep SU system of certification. Furthermore, SU have obligatory elements of quality documentation but only facultative quality indicator assessment for CPUs. From an economic viewpoint operation and procedural key (OPS) numbers guarantee a better reflection of the use of resources in the complex treatment of stroke, which could not yet be established for CPUs., Conclusion: The well-established CPU concept could additionally benefit from a superordinate quality control. Adequate quality benchmarking appears to be fundamental for gap analyses and for the establishment of a separate remuneration structure. In this respect the German Society for Cardiology as the certifying institution is required to establish an appropriate mechanism within the framework of regular updates of criteria., (© 2020. Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

In 2008, the German Cardiac Society (GCS) introduced a certification program for specialized chest pain units (CPUs). In order to benchmark the performance of the certified CPUs, a nationwide German CPU registry was established. Since then, data for more than 34,000 patients have been included. The concept of certified CPUs in Germany has been widely accepted and its success is underlined by its recent inclusion in national and international guidelines. As of December 2019, 286 CPUs have been successfully certified or recertified by the GCS. This review focuses on the data retrieved from the CPU registry during the first decade of certification. As demonstrated by 16 manuscripts stemming from the registry, certified German CPUs demonstrate high quality of care in acute coronary syndrome and beyond. It is also noted that the German CPU registry allowed for further analysis of the gap in guideline adherence. With the current update of the CPU certification criteria, central data collection as a best-practice criterion will be abandoned, and after some productive years the registry has temporarily been stopped.

Background: Chest pain units (CPUs) and stroke units (SUs) provide specialized multidisciplinary in-hospital management for acute chest pain and ischemic stroke. We analyzed exemplary equivalent quality benchmarks in both concepts., Material and Methods: Data from the German CPU registry (2012-2015; 45 certified CPUs, 5881 patients) were compared with data from the SU registry of Rhineland-Palatinate (2011-2015; 29 SUs; 40,380 patients). Parameters comprised demographics, symptoms, diagnosis, medication, critical time intervals, therapeutics, and in-unit outcome., Results: Non-ST-segment elevation myocardial infarction (47.4%) and ischemic stroke (63.0%) were the most frequent entities. An electrocardiogram was performed on average within 7 min in CPUs, cranial imaging within 49 min in SUs. The mean time interval from admission until coronary intervention or lysis was 42 min or 57 min, respectively. Rates of antiplatelet therapy (90.1% vs. 96.0%), brain imaging, and coronary angiography were high (99.3% vs. 81.1%) and the mortality was low (0.8% for CPUs vs. 3.6% for SUs). The length of stay was shorter in CPUs (1.5 days vs. 4.4 days)., Conclusion: As reimbursement for emergency medicine in Germany was recently rearranged, quality benchmarking has gained incremental importance. Mandatory joint quality measurement in both concepts ensuring gap analysis and process improvement is encouraged.

Introduction: Since 2008, specialized chest pain units (CPUs) were implemented across Germany ensuring structured diagnostics in acute chest pain. This study aims to analyze the management of pulmonary embolism (PE) patients in such certified CPUs., Methods: Data were retrieved from 13,902 patients enrolled in the German CPU registry and analyzed for the diagnosis of PE including patient characteristics, critical time intervals, diagnostic workup, treatment, and prognosis. PE patients were compared to the overall CPU patient cohort. Only patients with a complete 3-month follow-up were included., Results: Overall, 1.1% of all CPU patients were diagnosed with PE. Chest pain and dyspnea were the leading symptoms. Patients with PE were older, presented with higher heart rates, and more frequently exhibited signs of heart failure, despite a normal left ventricular function. PE patients showed significantly longer time delays between symptom onset and the first medical contact, while PE patients with chest pain presented earlier than PE patients with dyspnea only. Whereas more PE patients had to be transferred to the intensive care unit, in-CPU mortality and event rates over 3 months were low., Discussion/conclusion: This study suggests a certain risk for underdiagnosis and consecutive potential undertreatment of PE patients in German Cardiac Society (GCS)-certified CPUs, which is thought to result from an anticipated focus on patients with acute coronary syndrome (ACS). Public awareness for PE beyond chest pain should be improved. Certified CPUs should be urged to implement strategic pathways for a better simultaneous diagnostic workup of differential diagnosis beyond ACS., (© 2021 S. Karger AG, Basel.)

Background : Endovascular venous stenting with dedicated venous stents for the treatment of chronic venous outflow obstruction is developing as efficacious alternative to conservative therapy or open surgery. However, so far, mid- and long-term evidence on effectiveness and safety is poor. Patients and methods : The prospective, single-center, observational study enrolled consecutive patients with chronic non-thrombotic iliac vein lesions (NIVL) or post-thrombotic iliofemoral obstructions (PTO). From February 2016 to April 2017, patients underwent implantation of open cell, self-expandable dedicated venous stents. Short-term symptomatic improvement, patency, and complication rate were favorable. Evaluation at 2-years included improvement in the revised venous clinical severity score (rVCSS), patency, stent migration, major target limb events, clinically important pulmonary embolism, major bleeding, and all-cause mortality. Results : A total of 79 patients (57 ± 16 years, 44 female) were evaluated. At 2 years, rVCCS improved by 4.3 ± 2.7 (p < 0.001). Substantial clinical improvement of ≥ 2 score points was achieved in 86.4% (38 of 44) of patients. Improvement was not associated with thrombotic pathogenesis (regression coefficient [B] with PTO = 0.6 [95%CI: -1.1 to 2.3], p = 0.48). At 2 years, all ulcers (in 8 of 79 patients) were healed and none recurred. Two-year primary patency was 95.5% (95%CI: 86.5 to 98.5) with no difference between NIVL- and PTO-patients (log-rank p = 0.83). Target vessel revascularization was conducted in two PTO- and one NIVL-patients in the period of 34 days to 156 days from index procedure, resulting in a secondary patency of 100%. No stent migration, target limb deep vein thrombosis, major amputation, pulmonary embolism, or death occurred. Conclusions : Venovo venous open cell self-expanding stent implantation for chronic outflow obstruction was efficacious and provided a sufficient level of safety throughout 2 years.

Background: We sought to determine structure and changes in organisation and bed capacities of certified German chest pain units (CPU) in response to the emergency plan set-up as a response to the SARS-CoV-2 pandemic., Methods and Results: The study was conducted in the form of a standardised telephone interview survey in certified German CPUs. Analyses comprised the overall setting of the CPU, bed capacities, possibilities for ventilation, possible changes in organisation and resources, chest pain patient admittance, overall availability of CPUs and bail-out strategies. The response rate was 91%. Nationwide, CPU bed capacities decreased by 3% in the early phase of COVID-19 pandemic response, exhibiting differences within and between the federal states. Pre-pandemic and pandemic bed capacities stayed below 1 CPU bed per 50,000 inhabitants. 97% of CPUs were affected by internal reorganisation pandemic plans at variable extent. While we observed a decrease of CPU beds within an emergency room (ER) set-up and on intermediate care units (ICU), beds in units being separated from ER and ICU were even increased in numbers., Conclusions: Certified German CPUs are able to maintain adequate coverage for chest pain patients in COVID-19 pandemic despite structural changes. However, at this time, it appears important to add operating procedures during pandemic outbreaks to the certification criteria of forthcoming guidelines either at the individual CPU level or more centrally steered by the German Cardiac Society or the European Society of Cardiology.

Purpose: To assess the practical application and acute outcomes of the Tack Endovascular System for infrainguinal dissection repair in a real-world setting. Materials and Methods: Fifty-one consecutive patients who underwent endovascular revascularization for symptomatic peripheral artery disease and experienced 63 dissections requiring treatment were included in the prospective, single-center, single-arm study between January and June 2019. Thirty-nine (76.5%) lesions were ≥10 cm in length, 33 (64.7%) were totally occluded, and 13 (25.5%) were severely calcified. Fifty-six (88.9%) dissections were classified as severe. Dissections were treated either by means of the 6-F above-the-knee (ATK) or the 4-F below-the-knee (BTK) Tack Endovascular System. Observational outcomes were conditions and scopes of application. Clinical outcomes were acute technical and procedural success as well as safety. Results: Lesions were revascularized with 2.3±0.8 attempts such as standard balloon angioplasty, drug-coated balloon angioplasty, atherectomy, and/or lithotripsy. The Endovascular System was applied in 60 (95.2%) of 63 dissections. All dissections of the femoral artery were treated with the ATK system, and all infrapopliteal dissections with the BTK system. Both systems were successfully applied in popliteal artery dissections. Dissection length predicted the number of Tack implants deployed. Technical success was achieved in 98.3% (59 of 60 dissections). No major adverse event or device-related complication occurred during the procedure. Conclusion: Acute results in effectiveness and safety of the Tack Endovascular System for infrainguinal dissection repair in a real-world setting are promising.

Introduction: Gender-specific atypical clinical presentation in acute coronary syndrome and sex-specific outcomes in cardiovascular disease in women are well known. The aim of this study is to analyze possible differences between men and women presenting to certified German chest pain units (CPUs)., Methods: Data from 13,900 patients derived from the German CPU registry were analyzed for gender differences in patient characteristics, cardiovascular disease manifestation, critical time intervals, treatment and prognosis., Results: A total of 37.8% of patients were female. Typical chest pain occurred more frequently in men, while atypical symptoms occurred more frequently in women. Female gender was associated with longer pre- and in-hospital time delays. Women were more often diagnosed with a nonischemic origin of pain. In a 3-month follow-up, there was no gender-specific difference in combined major adverse coronary and cerebrovascular events., Discussion/conclusion: This study points out gender-specific differences in prehospital time intervals and a significantly higher percentage of atypical symptoms in suspected myocardial ischemia as well as more noncoronary diagnoses in women. Symptom awareness and a broader diagnostic workup in women are essential., (© 2020 S. Karger AG, Basel.)

Background: Previous studies showed favorable results after treatment of femoropopliteal lesions with the Pulsar-18 self-expanding (SE) nitinol stent. The objective of this registry was to evaluate whether these results will be confirmed in a real-world setting with varying stenting strategies. Patients and methods: In this prospective, observational trial, 160 patients with 186 femoropopliteal lesions were treated with the Pulsar-18 SE nitinol stent at 9 German sites. Mean lesion length was 116 ± 103 mm, and 41.9 % of the lesions were moderately or heavily calcified. Eighty lesions were concomitantly treated with drug-coated balloon (DCB). Main effectiveness outcome was primary patency at 12 months, and main safety outcome was freedom from the composite of device or procedure related death, major target limb amputation, and clinically driven target lesion revascularization (TLR) at 30 days and 6 months. Results: Kaplan-Meier estimate of primary patency was 89.1 %, 67.3 %, and 57.1 % at 6, 12, and 24 months. Freedom from TLR was 95.5 %, 91.4 %, and 85.2 % at 6, 12, and 24 months, respectively. Lesions, which were additionally treated with DCB (plus DCB-group), were longer (150 versus 82 mm on average, p < 0.0001), and associated with lower primary patency estimates than those without DCB angioplasty (stent-only-group) (log-rank p = 0.006). However, there was no difference in freedom from TLR between groups (log-rank p = 0.542). Improvement by ≥ 1 Rutherford category was achieved in 84.8 %, 81.0 %, and 81.7 % of patients at 6, 12, and 24 months, respectively. Walking distance and patient-reported pain improved persistently through 24 months (p < 0.001). Hemodynamic improvement was achieved in 68.2 %, 73.7 %, and 70.7 % of the patients at 6, 12, and 24 months, respectively. Conclusions: The Pulsar-18 self-expanding nitinol stent with optional drug-coated balloon angioplasty can be considered an efficacious and safe therapy option for endovascular treatment of femoropopliteal artery disease.

Background: Percutaneous mechanical thrombectomy (PMT) represents a treatment option in addition to conventional therapy for patients with iliofemoral deep vein thrombosis (DVT). We sought to determine the safety, patency and short-term outcome of the Aspirex ® S catheter as a rotational mechanical thrombectomy device in the endovascular treatment of iliofemoral DVT. Patients and methods: 56 patients (66 % female, median age 51 years) undergoing mechanical thrombectomy with the Aspirex ® S catheter for endovascular treatment of iliofemoral DVT were included in the analysis. Device- and procedure-related complications, prevention of post-thrombotic syndrome (PTS) and patency rates were determined at baseline and at 1, 6 and 12 months after intervention. Results: No device-related complications or malfunction occurred. Procedure-related complications (rehospitalization, re-occlusion of target vein, prolonged hospitalization resulting from access site complication) were seen in 14 % of patients. PMT was followed by implantation of a dedicated venous stent in all patients. Low PTS reflected by a revised venous clinical severity score (rVCSS) of < 3 and a clinical, etiologic, anatomic and pathophysiologic (CEAP) score of < 3 were achieved in 64 % of the patients at 12 months. Patency was 95 % after 1 month, 94 % after 6 months and 87 % after 12 months. Conclusions: Even though long-term studies are missing, PMT of iliofemoral DVT using the Aspirex ® S rotational thrombectomy device as a standalone approach exhibited an excellent patency at short term associated with substantial prevention of moderate to severe PTS and low device-related complications including bleeding.

Background: We sought to determine the patency and clinical symptom relief following the usage of the sinus-Obliquus venous stent in the endovascular treatment of venous obstruction of the ilio-femoral track in short-term. Patients and methods: 48 patients (62 % female, mean age 57 years) with chronic unilateral post-thrombotic obstruction (PTO) and non-thrombotic iliac vein obstructive lesions (NIVL) without involvement of inferior vena cava receiving a sinus-Obliquus venous stent was included in the analysis. Clinical improvement determined by the revised venous clinical severity score (rVCSS) as well as the clinical, etiologic, anatomic and pathophysiologic score (CEAP), safety, and stent patency rates were determined at baseline and at 1, 6 and 12 months after stent placement. Ten of the 48 included patients had a venous ulceration. Results: Primary patency rates were 98 % at FU1, 94 % at FU2 and 94 % at FU3, respectively. Secondary patency was 100 % at FU1, 96 % at FU2 and remained 96 % at FU3. At 12 months, the mean rVCSS dropped from 9.0 to 4.8 points (p < 0.001) whereas the mean CEAP improved from 3.45 to 2.96 (p < 0.001). A substantial healing of ulcerations was observed in 8 of 10 patients with initial venous ulceration. There were no relevant safety concerns noticed. Conclusions: Even though long-term studies are missing, the sinus-Obliquus venous stent already showed very promising patency rates at short term, associated with substantial clinical improvement and low device-related complications in both NIVL and PTS.

Background: We sought to determine the patency and clinical symptom relief of the Venovo venous stent in the endovascular treatment of non-thrombotic (NIVL) or post-thrombotic venous obstruction (PTO) of the iliofemoral track over a period of 6 months., Patients and Methods: A total of 80 patients (45 female, mean age 57 years) treated in 2016 and 2017 were included in the Arnsberg venous registry. Clinical improvement was determined by the revised venous clinical severity score (rVCSS) as well as the clinical, etiologic, anatomic and pathophysiologic (CEAP) score. Primary and secondary stent patency was evaluated using duplex ultrasound., Results: Overall 6-months patency rates were 98 % for primary and 100 % for secondary patency. For NIVL primary patency was 97 %, whereas for PTO primary patency was 96 %. Early stent re-occlusion occurred in 3 patients within 34, 59 and 156 days after intervention. Two of these patients were successfully treated by endovascular mechanical thrombectomy and stent in stent implantation. Clinical improvement with a gain of ≥ 2 rVCSS levels was observed in 51 %. CEAP scores decreased from 4.3 to 2.7., Conclusions: In this first time report the novel Venovo venous stent showed adequate patency rates associated with reasonable clinical improvement and low device-related complications throughout a 6-months-follow-up in both NIVL and PTO.

The nationwide German certification process of specialized chest pain units is unique in Europe. By February 2018, 269 units had already been successfully certified. With that number, more than half of all catheter laboratories across the country offering service on a 24/7 basis for interventional treatment in myocardial infarction take part in that certified chest pain program - with still increasing tendency. Currently, those units provide a mean of one chest pain unit bed per 65,000 inhabitants. Thereby, a high percentage of recertification of about 95% reflects a high acceptance of the concept by the health care providers. Structured in-hospital procedures, increasing awareness within the community and among the emergency medical services as well as increasing numbers of self-referrals guarantee higher work-flow, improving performance and an even increasing demand for those units. Complimentary patient awareness campaigns focusing on early symptom recognition might further improve, expand and redirect patient flow, shorten patient-related delay and have to become the next level in chest pain patient care in Germany. Transferring the idea of early heart attack care to the community as a new way of thinking might be able to more significantly decrease future symptoms-to-therapy times as the current chest pain unit program can solely achieve.

Background: To evaluate the performance of a closed-cell designed venous stent for the treatment of chronic ilio-femoral venous outflow obstruction (VOO) in the shortterm., Patients and Methods: Safety, stent patency and clinical outcome after placement of the Vici Venous Stent® in patients with chronic ilio-femoral venous obstruction were assessed retrospectively. Stent patency was evaluated by duplex ultrasound scanning, and clinical outcome was determined using the revised Venous Clinical Severity score (rVCSS)., Results: 75 patients (49 % female; median age 57 years; 82 limbs) with symptomatic significant VOO had stents placed in the ilio-femoral veins. Lower limb venous skin changes including ulcers (C-class in CEAP 4-6) were found in 31 patients (41 %). Nonthrombotic iliac vein lesions (NIVLs) and post-thrombotic obstruction (PTO) were found in 40 and 42 limbs, respectively. There were no safety issues. Cumulative primary, assisted-primary, and secondary stent patency in the entire cohort at 12 months were 94 %, 94 % and 96 %, respectively. Five limbs presented with stent occlusion. Two limbs had no intervention, 2/3 remained patent after reintervention. Clinical improvement (a decrease ≥ 2 rVCSS points) was observed in 81 %, 81 %, and 77 % of patients at 1 month, 6 months, and 12 months, respectively. There was a marked drop in the frequency of more marked pain and swelling (VCSS ≥ 2) from 62 % to 5 % and 93 % to 19 %, respectively. Four limbs had venous ulcers, three healed during the follow-up. Cumulative pri- mary stent patency at 12 months was 100 % and 87 % in patients with NIVL and PTO, respectively (p= 0.032). There was no statistical difference in clinical outcome between these subgroups., Conclusions: The Vici Venous Stent® placed in the ilio-femoral vein segment in patients with symptomatic VOO revealed no safety issues, had excellent primary patency and substantial symptom improvement. Long-term studies are needed to evaluate the durability of this stenting procedure.

Background: The aim of this study was to evaluate 12-month effectiveness of the endovascular treatment of femoropopliteal (FP) atherosclerotic lesions with the Ranger drug-coated balloon (DCB) in a real-world setting., Methods: In this prospective, observational, multicenter trial (ClinicalTrials.gov Identifier: NCT02462005) 172 consecutive patients with 226 de novo, restenosed, or reoccluded native superficial femoral and/or popliteal artery lesions were treated with the Ranger paclitaxel-coated balloon angioplasty. Mean lesion length was 129 mm (5-400 mm). Fifty-nine (26%) of 226 lesions were moderately or heavily calcified. Provisional stenting was conducted in 55 (22%) of 226 lesions. Main effectiveness outcomes were procedural success, 6- and 12-month hemodynamic or clinical improvement, and primary patency based and clinically driven target lesion revascularization (TLR) at 6 and 12 months., Results: Procedural success (<30% residual stenosis and no major adverse event within 30 days) was achieved in 126 (73%) of 172 patients with DCB alone and in all patients if bailout procedures were included. Primary patency was 91.0% at 6 months and 84.1% at 12 months. Freedom TLR was 92.4% at 6 months and 89.2% at 12 months. ABI, pain-free walking distance and Rutherford category improved significantly (P<0.001) after 6 and 12 months., Conclusions: Results suggest that angioplasty with the Ranger paclitaxel-coated balloon with provisional stenting is efficacious for the treatment of a broad range of femoropopliteal atherosclerotic lesions. No safety concerns arose.

Background: Atrial fibrillation (AF) and coronary artery disease (CAD) may be encountered coincidently in a large portion of patients. However, data on coronary artery calcium burden in such patients are lacking. Thus, we sought to determine the value of cardiac computed tomography (CCT) in patients presenting with new-onset AF associated with an intermediate pretest probability for CAD admitted to a chest pain unit (CPU)., Methods: Calcium scores (CS) of 73 new-onset, symptomatic AF subjects without typical clinical, electrocardiographic, or laboratory signs of acute coronary syndrome (ACS) admitted to our CPU were analyzed. In addition, results from computed tomography angiography (CTA) were related to coronary angiography findings whenever available., Results: Calcium scores of zero were found in 25%. Median Agatston score was 77 (interquartile range: 1-270) with gender- and territory-specific dispersal. CS scores above average were present in about 50%, high (> 400)-to-very high (> 1000) CS scores were found in 22%. Overall percentile ranking showed a relative accordance to the reference percentile distribution. Additional CTA was performed in 47%, revealing stenoses in 12%. Coronary angiography was performed in 22% and resulted in coronary intervention or surgical revascularization in 7%. On univariate analysis, CS > 50th percentile failed to serve as an independent determinant of significant stenosis during catheterization., Conclusions: Within a CPU setting, relevant CAD was excluded or confirmed in almost 50%, the latter with a high proportion of coronary angiographies and subsequent coronary interventions, underlining the diagnostic value of CCT in symptomatic, non-ACS, new-onset AF patients when admitted to a CPU.

Background: Regional healthcare projects improve the off-hour care of patients with acute coronary syndromes and persistent ST-segment elevation myocardial infarction (STEMI). To analyse differences in quality of care between on and off-hour care of STEMI patients admitted to certified German chest pain units., Methods: A total of 1107 STEMI patients from the German chest pain unit registry were enrolled. Analyses comprised critical time intervals (symptoms to first medical contact (FMC), FMC to admission, symptoms to admission, symptoms to balloon, FMC to balloon, door to balloon times) and major adverse cardiac and cerebrovascular events at follow-up., Results: 54.8% of patients were admitted off-hours. Symptoms to admission (2:28 (1:28-5:20 h) vs. 3:16 h (1:35-8:06 h), P<0.001), symptoms to FMC (1:15 h (0:33-3:00 h) vs. 2:00 h (0:40-6:46 h), P<0.001) and FMC to admission intervals (0:45 h (0:30-1:20 h) vs. 0:52 h (0:32-1:35 h), P=0.09) were shorter during off-hours. Percutaneous revascularisation rates were high and without difference between on and off-hours (95.5% vs. 96.8%, P=0.30). Door to balloon times were significantly less during on-hours (0:32 h (0:18-1:06 h) vs. 0:44 h (0:23-1:20 h), P<0.01) without negative impact on the proportion of patients with a door to balloon time of <60 min (72.6% vs. 68.4%, P=0.19), symptoms to balloon (3:49 h (2:12-10:46 h) vs. 3:30 h (2:04-7:41 h), P=0.08) or FMC to balloon times (1:26 h (0:56-2:22 h) vs. 1:30 h (1:03-2:29 h), P=0.14). Major adverse cardiac and cerebrovascular event rates did not differ significantly between on and off-hours (log-rank test P=0.36)., Conclusions: The German chest pain unit network ensures rapid and structured preclinical and in-hospital care independent from the circadian variation of admission. Slower door to balloon times off-hours are compensated by faster symptoms to admission or symptoms to FMC intervals. Further efforts should focus on patient awareness programmes on-hours and STEMI alarming tracks off-hours.

Aim: To analyse the timing of cardiac troponin (cTn) measurements in high-risk and cTn-positive acute coronary syndromes without persistent ST-segment elevation (NSTE-ACS) in two structurally different German chest pain units (CPUs), contrasting an urban university maximum care and a rural regional primary care facility., Methods: All patients encoded as NSTEMI during the year 2013 were retrospectively enrolled in two centres: site (I)--centre of maximum care in an urban university setting and site (II)--centre of primary care in a rural regional care setting. Data acquisition included time intervals from admission to baseline cTn and first and second cTn control as well as type and timing of invasive management., Results: The median times (site I vs. site II) from admission to cTn result announcement were 26.5 vs. 33.0 min (p = 0.02) for baseline, 4 vs. 4 h (p = 0.43) for the first and 11.0 vs. 16.5 h (p = 0.03) for the second control. Timely announcement, as recommended by guidelines, was available in 86.9% at baseline, 59.4% for the first or 41.1% for the second cTn control. Rates and timing of invasive management were independent from the time point of positive cTn announcement (p = 0.51 and p = 0.68, respectively)., Conclusions: German CPUs provide timely identification of cTn-positive patients in a narrow and guideline-adherent time frame using a rapid rule-out protocol. Especially, baseline and early cTn timing was comparable between the urban university maximum care and the rural regional primary care facility without relevant impact on guideline-conforming invasive management, underlining the high standard of care in those highly professional institutions.

Objective: In an effort to provide a systematic and specific standard-of-care for patients with acute chest pain, the German Cardiac Society introduced criteria for certification of specialized chest pain units (CPUs) in 2008, which have been replaced by a recent update published in 2015., Methods: We reviewed the development of CPU establishment in Germany during the past 7 years and compared and commented the current update of the certification criteria., Results: As of October 2015, 228 CPUs in Germany have been successfully certified by the German Cardiac Society; 300 CPUs are needed for full coverage closing gaps in rural regions. Current changes of the criteria mainly affect guideline-adherent adaptions of diagnostic work-ups, therapeutic strategies, risk stratification, in-hospital timing and education, and quality measures, whereas the overall structure remained unchanged. Benchmarking by participation within the German CPU registry is encouraged., Conclusion: Even though the history is short, the concept of certified CPUs in Germany is accepted and successful underlined by its recent implementation in national and international guidelines. First registry data demonstrated a high standard of quality-of-care. The current update provides rational adaptions to new guidelines and developments without raising the level for successful certifications. A periodic release of fast-track updates with shorter time frames and an increase of minimum requirements should be considered.

Objective: The German Cardiac Society runs a nation-wide certification campaign for specialized chest pain units (CPUs). So far, cardiac computed tomography (CT) is not an integral part of such certification. The aim of our study was to analyze whether or not cardiac CT is nevertheless routinely used for further stratification in low-risk patients., Methods: For the time interval from January 2010 to April 2011, data were retrieved from the mandatory German CPU registry. Patients with and without cardiac CT during CPU index stay were compared., Results: Out of 5800 patients, 314 patients (5.4%) underwent cardiac CT during the index CPU stay. Unstable angina pectoris was the most common diagnosis when performing cardiac CT [34.4% vs. 17.7%; odds ratio (OR), 2.44; confidence interval (CI), 1.91-3.11; P < 0.001). Patients undergoing cardiac CT received significantly less often coronary angiography (31.8% vs. 54.8%; OR, 0.39; CI, 0.30-0.49; P < 0.001) or coronary revascularization (15.6% vs. 36.5%; OR, 0.32; CI, 0.23-0.46; P < 0.001). The use of cardiac CT did not prolong the length of stay in the CPU (20:48 vs. 20:25 h, P = 0.21)., Conclusions: Cardiac CT is underrepresented within the diagnostic work up in certified CPUs in Germany, although its use reduces unnecessary invasive diagnostics. The use of cardiac CT should be reconsidered during the next update of the CPU certification criteria.

Background: About 10% of patients admitted to a chest pain unit (CPU) exhibit atrial fibrillation (AF)., Hypothesis: To determine whether calcium scores (CS) are superior over common risk scores for coronary artery disease (CAD) in patients presenting with atypical chest pain, newly diagnosed AF, and intermediate pretest probability for CAD within the CPU., Methods: In 73 subjects, CS was related to the following risk scores: Global Registry of Acute Coronary Events (GRACE) score, including a new model of a frequency-normalized approach; Thrombolysis In Myocardial Infarction score; European Society of Cardiology Systematic Coronary Risk Evaluation (SCORE); Framingham risk score; and Prospective Cardiovascular Münster Study score. Revascularization rates during index stay were assessed., Results: Median CS was 77 (interquartile range, 1-270), with higher values in men and the left anterior descending artery. Only the modified GRACE (ρ = 0.27; P = 0.02) and the SCORE (ρ = 0.39; P < 0.005) were significantly correlated with CS, whereas the GRACE (τ = 0.21; P = 0.04) and modified GRACE (τ = 0.23; P = 0.02) scores were significantly correlated with percentile groups. Only the CS significantly discriminated between those with and without stenosis (P < 0.01)., Conclusions: Apart from modified GRACE score, overall correlations between risk scores and calcium burden, as well as revascularization rates during index stay, were low. By contrast, the determination of CS may be used as an additional surrogate marker in risk stratification in AF patients with intermediate pretest likelihood for CAD admitted to a CPU., (© 2016 Wiley Periodicals, Inc.)

Objectives: To analyze the current usage of transthoracic echocardiography (TTE) as a rapid, noninvasive tool in the early stratification of acute chest pain in certified German chest pain units (CPUs)., Methods: A total of 23,997 patients were enrolled. Analyses comprised TTE evaluation rates in relation to clinical presentation, risk profile, left ventricular impairment, final diagnosis and invasive management. Critical times were assessed. Multivariable analyses for independent determinants for the use of TTE were performed., Results: TTE evaluation was available in CPUs in 70.1% of cases. It was associated with lower rates of invasive management in unstable angina pectoris (UAP) and with higher rates in patients with initially suspected non-cardiac origin of symptoms and/or reduced systolic function (p < 0.05). Non-ST-segment elevation acute coronary syndrome (NSTE-ACS) was an independent determinant favoring TTE evaluation [NSTE-myocardial infarction: odds ratio (OR) 1.62; UAP: OR 1.34; p < 0.001 for both]. Clinical signs of heart failure (OR 1.31; p < 0.001), referral by emergency medical service (OR 1.18; p < 0.001) and kidney failure (OR 1.16; p < 0.05) were independently associated with higher TTE rates. TTE did not delay door-to-balloon times., Conclusions: About two thirds of the patients admitted to certified CPUs received TTE evaluation, with the highest rates being in ACS patients, and thereby providing diagnostic information supporting or refuting further invasive management., (© 2016 S. Karger AG, Basel.)

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., (Copyright © 2014 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.)

Objective: The implementation of chest pain centers (CPC)/units (CPU) has been shown to improve emergency care in patients with suspected cardiac ischemia., Methods: In an effort to provide a systematic and specific standard of care for patients with acute chest pain, the Society of Cardiovascular Patient Care (SCPC) as well as the German Cardiac Society (GCS) introduced criteria for the accreditation of specialized units., Results: To date, 825 CPCs in the United States and 194 CPUs in Germany have been successfully certified by the SCPC or GCS, respectively. Even though there are differences in the accreditation processes, the goals are quite similar, focusing on enhanced operational efficiencies in the care of the acute coronary syndrome patients, reduced time delays, improved diagnostic and therapeutic strategies using adapted standard operating procedures, and increased medical as well as community awareness by the implementation of nationwide standardized concepts. In addition to national efforts, both societies have launched international initiatives, accrediting CPCs/CPU in the Middle East and China (SCPC) and Switzerland (GCS)., Conclusion: Enhanced collaboration among international bodies interested in promoting high quality care might extend the opportunity for accreditation of facilities that treat cardiovascular patients, with national programs designed to meet local needs and local healthcare system requirements.

Purpose: To evaluate the patency and the freedom of target lesion revascularization of the 4-French Pulsar-18 self-expandable (SE) nitinol stent for the treatment of long femoropopliteal occlusive disease in a two-center, prospective, all-comers registry with a follow-up period of 12 months., Methods: This registry enrolled 36 patients with symptomatic femoropopliteal long lesions for recanalization and implantation of the 4-French Pulsar-18 SE nitinol stent. Routine follow-up examination including duplex ultrasound was performed after 6 and 12 months. Primary patency was defined as no binary restenosis on duplex ultrasound (Peak systolic velocitiy ration (PSVR) <2.5) and no target lesion revascularization was performed within 12 months' follow-up. No drug-eluting devices were allowed in this registry., Results: Average lesion length of the femoropopliteal segment was 182.3 ± 51.8 mm. Mean stent implantation length was 181.5 ± 35.4 mm. Total occlusion was present in 46 of the 48 (95.8%) treated lesions. Involvement of popliteal segment I-III was present in 3 (6.3%) lesions. The primary patency after 6 and 12 months was 87.5% and 85.4%, respectively. The clinically driven overall freedom from target lesion revascularization (fTLR) was 89.6% after 6 months and 87.5% after 12 months. ABI, pain-free walking distance and Rutherford category, all improved significantly (P < 0.001) after 6 and 12 months. The primary patency rate in patients with diabetes (P = 0.18) and renal insufficiency (P = 0.3) was not significantly lower as compared to the overall primary patency., Conclusions: In this two-center, all-comers registry, the use of the Pulsar-18 SE nitinol stent for endovascular intervention of femoropopliteal disease with a mean lesion length of 182.3 ± 51.8 mm showed promising primary patency and fTLR rates after 6 and 12 months. Diabetes and renal insufficiency had no negative impact on the patency rate.

Objective: Management of acute coronary syndromes without persistent ST-segment elevation (NSTE-ACS) and unstable angina pectoris (UAP) remains challenging. The study aimed to analyze the current management of UAP patients in German chest pain units focussing on the different time lines of invasive strategy., Methods: A total of 1400 UAP patients admitted to a certified chest pain unit were enrolled. Analyses of high-risk criteria with indication for invasive management and of 3-month clinical outcomes were performed by subgrouping UAP patients to immediate and early invasive (<8 hours), early elective invasive (8-24 hours), late elective invasive (24-72 hours) strategy, and without percutaneous coronary intervention (PCI)., Results: Coronary angiography was performed in 60.6% of the UAP patients, whereas PCI was necessary in 37%. Only 1.4% of the UAP patients obtained immediate PCI within the first 120 minutes. In 16.9%, patients received PCI within the first day of hospitalization or even within the first 8 hours after admission in another 7.7%, although the Global Registry of Acute Coronary Events (GRACE) score at admission was below 140. In the remaining 12.4% of the UAP patients, PCI was performed within 24-72 hours after admission. Those patients exhibited a higher prevalence of secondary risk markers than those with conservative treatment regimen., Conclusions: To date, almost two-third of UAP patients at intermediate to high risk receive rapid invasive regimen within the first 24 hours after admission. Oncoming studies will have to analyze its overall guideline-adherence and resulting differences in major adverse events.