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2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation

This thesis focuses on describing, understanding and improving telephone triage of patients with acute chest discomfort (pain, pressure or tightness) who call out-of-hours services for primary care (OHS-PC). (i) The Netherlands Triage Standard is used for telephone triage, but it performs poorly regarding both safety and efficiency in urgency assessment of patients with or without acute coronary syndrome or other life threatening events. Triage nurses’ overruling of the system recommended urgency increases the safety of telephone triage. (ii) Triage nurses create a ‘mental image’ of the patient to cope for the lack of visual information during telephone triage. ‘Congruence’ with the NTS is key for the working strategies of the triage nurses, defined as whether the system supports their decision making. (iii) The risk of an acute coronary syndrome among patients with chest discomfort is almost twice as high for patients calling at night (between 0.00-9.00 a.m.) as compared to patients who call at other hours; evidently in men, but less clearly in women. (iv) Symptoms predictive of an acute coronary syndrome are more similar than different for women and men with acute chest discomfort who call the OHS-PC. Ambulances are dispatched equally to women and men. (v) Among both women and men with chest discomfort, age, pressing/heavy chest pain, sweating and radiation of the pain are the strongest predictors for the diagnosis ACS.

In this thesis the trend over the last two decades of improved survival after a first hospitalisation for heart failure is shown in the Netherlands for both men and women. Furthermore it is shown that there is a relation between diabetes and stiffening of the heart, as well as heart failure, in both men and women. To evaluate the diagnostic and prognostic value of biomarkers in men and women with stiffening of the heart the HELPFul study was started. The rationale and design of this study is further explained in the this thesis. In this thesis the value of diagnostic models for heart stiffening and heart failure with preserved ejection fraction is tested and found to be reasonably effective. The role of worsening of the kidney function is examined, but after correction for potential confounders there was no longer a significant relationship with left ventricular diastolic dysfunction. In the different projects in this thesis large heterogeneity in between studies and in the definition of sitffening of the heart (left ventricular diastolic dysfunction) is found. These problems require further attention in the future if the these fields are to develop further. A individual patient data meta-analysis might be a solution to develop a new definition for left ventricular diastolic dysfunction.

This thesis focuses on the contemporary way in which telephone triage is carried out with the ‘Netherlands Triage Standard’ in callers with acute cardiovascular symptoms suggestive of transient ischaemic attack (TIA)/stroke or acute coronary syndrome (ACS) who call the out-of-hours service in primary care. (i) The ‘Netherlands Triage Standard’ performed moderately regarding safety (sensitivity) and poorly regarding efficiency (specificity) in allocating adequate urgencies to patients with and without TIA/stroke. (ii) We developed a new diagnostic prediction model for detecting TIA/stroke with telephone triage at the out-of-hours service in primary care, which had good discriminative ability with as strongest predictors age, female sex, arm weakness, and speech problems. (iii) Missed ACS patients largely overlap in characteristics with patients with symptoms suggestive of ACS but without such a serious adverse event. We could not identify characteristics of missed ACS that could be helpful for triage to help prevent future adverse outcomes in patients with chest discomfort. (iv) General practitioner experts rated - blinded to the outcome - the telephone triage of missed ACS patients more often as ‘unsafe’, and of ‘poor’ quality than that of patients with symptoms suggestive of ACS but without a serious adverse event. However, the level of agreement among experts was low. (v) Conversation analysis showed that the use of multiple-choice either/or-questions (e.g. “Is it an oppressive or stabbing or stinging pain?”) by the triage nurse can lead to difficulties in the interaction between the triage nurse and the caller.