Background: The prognostic significance of chest pain is well established in patients with coronary artery disease, but still ill defined in primary prevention. Therefore, the aim of our analysis was to assess the prognostic value of different forms of chest pain in a large cohort of primary care subjects under the conditions of contemporary modalities of care in primary prevention, including measurement of serum levels of the biomarker NT-pro-BNP. Design: We carried out a post-hoc analysis of the prospective DETECT cohort study. Methods: In a total of 5570 unselected subjects, free of coronary artery disease, within the 55,518 participants of the cross-sectional DETECT study, we assessed chest pain history by a comprehensive questionnaire and measured serum NT-pro-BNP levels. Three types of chest pain, which were any chest pain, exertional chest pain and classical angina, were defined. Major adverse cardiovascular events (MACEs = cardiovascular death, myocardial infarction, coronary revascularization procedures) were assessed during a 5-year follow-up period. Results: During follow-up, 109 subjects experienced a MACE. All types of reported chest pain were associated with an approximately three-fold increased risk for the occurrence of incident MACEs, even after adjusting for cardiovascular risk factors. Any form of reported chest pain had a similar predictive value for MACEs as a one-time measurement of NT-pro-BNP. However, adding a single measurement of NT-pro-BNP and the information on chest pain resulted in reclassification of approximately 40% of subjects, when compared with risk prediction based on established cardiovascular risk factors. Conclusions: In primary prevention, self-reported chest pain and a single measurement of NT-pro-BNP substantially improve cardiovascular risk prediction and allow for risk reclassification of approximately 40% of the subjects compared with assessing classical cardiovascular risk factors alone.

No description available.

Introdução: O manejo inadequado dos pacientes com dor torácica sugestiva de síndrome coronariana aguda (SCA) é fator de risco para morte ou outros eventos cardíacos adversos maiores (ECAM), o que contribui para o aumento da morbidade e mortalidade, do estresse da equipe e do paciente e maiores custos com o uso de serviços de saúde. Os protocolos de dor torácica para alta precoce (protocolos de diagnósticos acelerados ADP) surgem como instrumentos de melhoria da qualidade da assistência em departamentos de emergência (DE), possibilitando alta precoce (em até 6 horas) e segura a esses pacientes. Objetivo: Sintetizar as evidências científicas sobre a efetividade de protocolos de dor torácica na alta precoce e segura de adultos com sintomas sugestivos de SCA em DE, quando comparados ao tratamento usual ou outros protocolos de dor torácica (usual ou de alta precoce). Métodos: Revisão Sistemática (RS) da literatura que seguiu as recomendações do Joanna Briggs Institute. Para a busca dos estudos foi utilizada a estratégia PICOS (P= adultos (> 18 anos) com dor torácica sugestiva de SCA; I e C= protocolos de dor torácica utilizados para alta precoce; O= alta precoce e ECAM em 30 dias; e, S= ensaios clínicos randomizados, nas bases de dados: CINAHL, PubMed, Cochrane CENTRAL, LILACS, Web of Science, Scopus, EMBASE, além de banco de teses e dissertações de universidades dos quatro continentes. Não foi determinado limite temporal para a busca e esta foi finalizada em 31 de janeiro de 2018. A seleção inicial, avaliação inicial e qualidade metodológica dos estudos foi realizada por dois revisores independentes e as discordâncias foram resolvidas por consenso. A extração dos dados dos estudos foi feita pelo revisor primário, analisada, discutida e apresentada de forma descritiva e com metanálise. Resultados: Incluídos quatro estudos do tipo ensaio clínico randomizado controlado, sendo que os protocolos para alta precoce utilizadas e testadas nesses estudos foram: ADAPT-ADP, HEART Pathway, EDACS-ADP, 2-Hour Protocol e 4-Hour Protocol. Porém, devido a alta hetergneidade (I=91%) apenas dois estudos foram agrupados em metanálise e os resultados foram apresentados com gráficos de floresta. Para a alta precoce a estimativa de efeito sugeriu que os benefícios da alta precoce superam os malefícios, recomendando o uso de protocolos acelerados de dor torácica na prática assistencial de departamentos de emergência. Para ECAM, a metanálise foi inconclusiva. Conclusão: Os protocolos estudados são efetivos na alta precoce, porém ainda não há evidência suficiente para afirmar que essa alta precoce seja segura. Contudo, essa RS é um primeiro passo importante para provar que sua utilização é viável e facilitará a alta precoce e segura de DE. / Introduction: Inadequate management of patients with chest pain suggestive of acute coronary syndrome (ACS) is a risk factor for death or other major adverse cardiac events (MACE), which contribute to increased morbidity and mortality, team and patient stress, and a higher expenses with health services. Early-onset chest pain protocols (accelerated diagnostic protocols - ADPs) appear as tools for improving the quality of care in emergency departments (ED), enabling early and safe discharge (up to 6 hours) for these patients. Objective: To synthesize the scientific evidences about the effectiveness of chest pain protocols in the early and safe discharge of adults with symptoms suggestive of ACS in ED, when compared to the usual treatment or other protocols of chest pain (usual or early discharge). Methods: Systematic Review (SR) of the literature that followed the recommendations of the Joanna Briggs Institute. In order to search for the studies, the PICOS strategy was used (P = adults (> 18 years) with chest pain suggestive of ACS, I and C = thoracic pain protocols used for early discharge; O = early discharge and MACE in 30 days and S = randomized clinical trials found in the following databases: CINAHL, PubMed, Cochrane CENTRAL, LILACS, Web of Science, Scopus, EMBASE, as well as a thesis and dissertations bank from universities of the four continents. A time limit was not determined to end this research; however this was finalized on January 31, 2018. The initial selection, initial evaluation and methodological quality of the studies were performed by two independent reviewers and the disagreements were resolved by consensus. Data extraction from the studies was done by the primary reviewer, analyzed, discussed and presented in a descriptive form with meta-analysis. Results: Four randomized controlled trials were included, the earlydischarge protocols used and tested in these studies were: ADAPT-ADP, HEART Pathway, EDACS-ADP, 2-Hour Protocol and 4-Hour Protocol. However, there is high heterogeneity between the studies (I = 91%), only two studies were grouped in meta-analysis and the results present by the funnel plot. For early discharge, the effect estimate suggested that the benefits of early discharge exceed the harm, recommending the use of accelerated chest pain protocols in emergency department assistance practice. For ECAM, the meta-analysis was inconclusive. Is not enough to affirm that early discharge is higher in the experimental groups who were discharged by the new protocol. Conclusion: The protocols studied are effective at early, however there is still insufficient evidence to affirm that this early discharge is safe. But this SR is an important first step to prove that its use is feasible and will facilitate the early and safe discharge of ED.

Dor torácica é sintoma frequente em pacientes com cardiomiopatia crônica da doença de Chagas (CCDC). Embora, em muitos casos seja atribuído empiricamente a defeitos transitórios (isquêmicos) encontrados em cintilografia de perfusão miocárdica (CPM), ainda não há evidências científicas que embasem terapêutica adequada para essa condição. Objetivos: Testar a hipótese de que ocorra redução > 50% do déficit perfusional transitório e melhora sintomática e de qualidade de vida após tratamento oral com verapamil e ácido acetilsalicílico (AAS) em pacientes com CCDC e dor torácica. Métodos: Estudo prospectivo, unicêntrico, que incluiu pacientes submetidos a cinecoronariografia por dor torácica, em que não foram identificadas lesões obstrutivas coronarianas significativas (>30%) e não apresentavam disfunção ventricular moderada ou grave. Alterações de mobilidade segmentar na ventriculografia contrastada e epidemiologia sugestiva apontaram para CCDC, que foi confirmada por dois testes sorológicos distintos. Isquemia microvascular foi comprovada por CPM com escore diferencial (Summed Difference Score (SDS) >= 1). Avaliação de dor torácica e qualidade de vida foi realizada por aplicação de Questionário de Angina de Seattle (QAS) e EQ-5D no momento da inclusão e após 3 meses de tratamento com verapamil e AAS, quando a CPM também foi repetida. As comparações pré e pós-tratamento do EQ-5D, QAS e SDS na CPM foi realizada através de teste de Wilcoxon para amostras pareadas e não normalmente distribuídas. Resultados: Vinte e seis pacientes de ambos os gêneros (58% de mulheres), idade média de 64 ±10 anos, apresentaram melhora significativa de 62,5% no SDS após o tratamento (4,5 [4-9] vs 2 [0-4.25], p<0.001). Dos 26 pacientes, 20 apresentaram melhora do SDS, dentre os quais, 10 com SDS igual a zero, ou seja, sem evidência de déficit perfusional transitório após o tratamento. Em 4 pacientes não houve mudança no SDS e apenas 2 apresentaram piora do SDS. Houve melhora significativa no valor indexado do EQ-5D após os 3 meses de tratamento (0,63±0,11 vs 0,77±0,17, p<0.001), assim como nas 5 subáreas que compõem o QAS (p<0,001).Conclusões: O uso combinado de vasodilatador microvascular e antiplaquetário (verapamil + AAS) associou-se a significativa redução dos defeitos perfusionais transitórios sugestivos de isquemia microvascular e a melhora de dor torácica e qualidade de vida em pacientes com CCDC. Este estudo pioneiro embasa investigações futuras no intuito de sedimentar evidências, comparar a placebo por exemplo, com intuito de definir terapêutica em pacientes com CCDC sintomáticos com distúrbios microvasculares. / Chest pain is a common symptom in patients with chronic Chagas disease cardiomyopathy (CCDC). Although this might be explained by myocardial perfusion scintigraphy (MPS) evidence of regional microvascular disturbances in patients with angiographically normal coronary arteries, there is no standard evidence based therapy for this condition. Purpose: Evaluate the impact of verapamil and acetylsalicylic acid (ASA) on symptoms, quality of life and myocardial perfusion defects in CDC patients with chest pain and microvascular ischemia. Methods: 26 patients were evaluated in this clinical trial. CCDC was confirmed by 2 serologic tests. All of them had chest pain and no significant epicardial coronary artery lesions by coronarography or moderate/severe ventricle systolic dysfunction by left ventriculography. Questionnaires to evaluate quality of life (EQ-5D) and chest pain symptoms (Seattle Angina Questionnaire (SAQ)) and SPECT MPS (physical stress preferably) were performed before and three months after treatment with oral verapamil and ASA. Comparison of pre and post EQ-5D/SAQ and SPECT perfusion results were performed using Wilcoxon signed rank test for paired data. Results: Mean age was 64 ± 10 years, 15 (57,7%) men. SDS was significantly reduced by 55,6% after treatment (4,5 [4-9] vs 2 [0-4.25], p<0.001). Decrease in SDS was observed in 20 (77%) participants, of those ten (38,5%) exhibited a post-treatment SDS equals zero, i.e., had no more evidence of stress induced perfusion abnormalities. Four patients (15,3%) maintained SDS values and only 2 (7,7%) increased SDS after 3 months of medications. In the evaluation of quality of life and symptoms, enhancement in EQ-5D values (index value: 0,63±0,11 vs 0,77±0,17, p<0.001) and in all dimensions of QAS post treatment were also significant (improve > 10 points each, p<0,001). Conclusions: The combined use of a microvascular vasodilator and an antiplatelet agent seems to improve quality of life and chest pain symptoms and reduce ischemic perfusion abnormalities in patients with CCDC significantly. This study paved the way for an ongoing investigation aimed at getting more definitive evidence of benefit withthese drugs as compared to placebo in CCDC and idiopathic microvascular derangements.

Dor torácica é sintoma frequente em pacientes com cardiomiopatia crônica da doença de Chagas (CCDC). Embora, em muitos casos seja atribuído empiricamente a defeitos transitórios (isquêmicos) encontrados em cintilografia de perfusão miocárdica (CPM), ainda não há evidências científicas que embasem terapêutica adequada para essa condição. Objetivos: Testar a hipótese de que ocorra redução > 50% do déficit perfusional transitório e melhora sintomática e de qualidade de vida após tratamento oral com verapamil e ácido acetilsalicílico (AAS) em pacientes com CCDC e dor torácica. Métodos: Estudo prospectivo, unicêntrico, que incluiu pacientes submetidos a cinecoronariografia por dor torácica, em que não foram identificadas lesões obstrutivas coronarianas significativas (>30%) e não apresentavam disfunção ventricular moderada ou grave. Alterações de mobilidade segmentar na ventriculografia contrastada e epidemiologia sugestiva apontaram para CCDC, que foi confirmada por dois testes sorológicos distintos. Isquemia microvascular foi comprovada por CPM com escore diferencial (Summed Difference Score (SDS) >= 1). Avaliação de dor torácica e qualidade de vida foi realizada por aplicação de Questionário de Angina de Seattle (QAS) e EQ-5D no momento da inclusão e após 3 meses de tratamento com verapamil e AAS, quando a CPM também foi repetida. As comparações pré e pós-tratamento do EQ-5D, QAS e SDS na CPM foi realizada através de teste de Wilcoxon para amostras pareadas e não normalmente distribuídas. Resultados: Vinte e seis pacientes de ambos os gêneros (58% de mulheres), idade média de 64 ±10 anos, apresentaram melhora significativa de 62,5% no SDS após o tratamento (4,5 [4-9] vs 2 [0-4.25], p<0.001). Dos 26 pacientes, 20 apresentaram melhora do SDS, dentre os quais, 10 com SDS igual a zero, ou seja, sem evidência de déficit perfusional transitório após o tratamento. Em 4 pacientes não houve mudança no SDS e apenas 2 apresentaram piora do SDS. Houve melhora significativa no valor indexado do EQ-5D após os 3 meses de tratamento (0,63±0,11 vs 0,77±0,17, p<0.001), assim como nas 5 subáreas que compõem o QAS (p<0,001).Conclusões: O uso combinado de vasodilatador microvascular e antiplaquetário (verapamil + AAS) associou-se a significativa redução dos defeitos perfusionais transitórios sugestivos de isquemia microvascular e a melhora de dor torácica e qualidade de vida em pacientes com CCDC. Este estudo pioneiro embasa investigações futuras no intuito de sedimentar evidências, comparar a placebo por exemplo, com intuito de definir terapêutica em pacientes com CCDC sintomáticos com distúrbios microvasculares. / Chest pain is a common symptom in patients with chronic Chagas disease cardiomyopathy (CCDC). Although this might be explained by myocardial perfusion scintigraphy (MPS) evidence of regional microvascular disturbances in patients with angiographically normal coronary arteries, there is no standard evidence based therapy for this condition. Purpose: Evaluate the impact of verapamil and acetylsalicylic acid (ASA) on symptoms, quality of life and myocardial perfusion defects in CDC patients with chest pain and microvascular ischemia. Methods: 26 patients were evaluated in this clinical trial. CCDC was confirmed by 2 serologic tests. All of them had chest pain and no significant epicardial coronary artery lesions by coronarography or moderate/severe ventricle systolic dysfunction by left ventriculography. Questionnaires to evaluate quality of life (EQ-5D) and chest pain symptoms (Seattle Angina Questionnaire (SAQ)) and SPECT MPS (physical stress preferably) were performed before and three months after treatment with oral verapamil and ASA. Comparison of pre and post EQ-5D/SAQ and SPECT perfusion results were performed using Wilcoxon signed rank test for paired data. Results: Mean age was 64 ± 10 years, 15 (57,7%) men. SDS was significantly reduced by 55,6% after treatment (4,5 [4-9] vs 2 [0-4.25], p<0.001). Decrease in SDS was observed in 20 (77%) participants, of those ten (38,5%) exhibited a post-treatment SDS equals zero, i.e., had no more evidence of stress induced perfusion abnormalities. Four patients (15,3%) maintained SDS values and only 2 (7,7%) increased SDS after 3 months of medications. In the evaluation of quality of life and symptoms, enhancement in EQ-5D values (index value: 0,63±0,11 vs 0,77±0,17, p<0.001) and in all dimensions of QAS post treatment were also significant (improve > 10 points each, p<0,001). Conclusions: The combined use of a microvascular vasodilator and an antiplatelet agent seems to improve quality of life and chest pain symptoms and reduce ischemic perfusion abnormalities in patients with CCDC significantly. This study paved the way for an ongoing investigation aimed at getting more definitive evidence of benefit withthese drugs as compared to placebo in CCDC and idiopathic microvascular derangements.

Las enfermedades cardiovasculares son la primera causa de mortalidad en los países industrializados y tradicionalmente han sido consideradas una patología predominantemente masculina. Las mujeres con enfermedad cardiovascular han sido tratadas siempre a imagen y semejanza de los varones, pero en los últimos años diferentes estudios han puesto de manifiesto la existencia de notables diferencias tanto en la fisiopatología de la enfermedad como en la respuesta a los tratamientos y en la actitud de los profesionales ante estas patologías. Son muchos los estudios que describen estas diferencias en cuanto al manejo de las enfermedades cardiovasculares más prevalentes en las pacientes hospitalizadas. Hasta ahora no se ha indagado sobre si existen diferencias a nivel de la asistencia urgente en los servicios de urgencias. El objetivo de esta tesis es conocer si existen o no diferencias de género en el tratamiento de cuatro patologías cardiovasculares muy prevalentes en los servicios de urgencias españoles: dolor torácico, síndrome coronario agudo sin elevación del segmento ST, insuficiencia cardiaca y fibrilación auricular. Para ello llevamos a cabo 4 estudios distintos en los que se tomaron diferentes muestras poblacionales correspondientes a servicios de urgencias hospitalarios españoles. En general, las mujeres fueron de mayor edad y superior comorbilidad, eran más hipertensas, más diabéticas y con mayor prevalencia de valvulopatías, mientras que los varones presentaron más frecuentemente antecedentes de cardiopatía isquémica y tabaquismo. En el primer estudio, sobre el manejo del dolor torácico en urgencias, no encontramos a grandes rasgos, diferencias en el manejo de los pacientes que acuden por dolor torácico a un servicio de urgencias dependientes de su género. Las pocas diferencias encontradas en algún segmento de edad, sobretodo en relación con las pruebas diagnósticas solicitadas, no se debieron al diferente manejo sino a la dificultad física presentada por las pacientes para realizar determinadas pruebas diagnósticas. En el segundo estudio, sobre el manejo del síndrome coronario agudo sin elevación del segmento ST, los resultados obtenidos indican que no existen diferencias en el manejo de esta patología en los servicios de urgencias dato que contrasta trabajos publicados tanto en Europa como en EEUU, donde el tratamiento a nivel hospitalario es menos intenso para las mujeres. Tampoco se observan diferencias entre sexos en el tercer estudio, sobre el abordaje de la insuficiencia cardiaca aguda. La práctica totalidad de las escasas diferencias encontradas se pudieron justificar por el diferente perfil clínico de los pacientes: perfil isquémico con disfunción sistólica en varones y perfil hipertenso y disfunción diastólica en mujeres. Tras la corrección por estos factores las mujeres resultaban más tratadas con digoxina y con menos ingresos en cardiología. En el cuarto estudio, sobre el manejo de la fibrilación auricular (FA) en los diferentes niveles asistenciales de un área básica de salud, encontramos alguna diferencia que pudo ser parcialmente explicada por el diferente perfil clínico de los pacientes; las mujeres reciben más frecuentemente digoxina al estar la FA asociada con más frecuencia en ellas a la presencia de insuficiencia cardiaca y ser mayores. Pero otras no tienen una explicación aparente y pueden poner de manifiesto algunas desigualdades, como por ejemplo la menor valoración de las mujeres por parte de un cardiólogo o su menor conocimiento del tratamiento recibido. Tras la realización de esta tesis doctoral podemos concluir que no existen, a grandes rasgos, diferencias en el tratamiento inicial de estas cuatro patologías en los servicios de urgencias hospitalarios españoles. Aunque hemos encontrado variaciones para algún subgrupo de pacientes y para alguna patología en concreto, parece que estas diferencias no se basan en el género del paciente sino en el diferente perfil clínico que presenta. / “GENDER DIFFERENCES IN THE APPROACH OF CARDIOVASCULAR DISEASE: AN APPROXIMATION FROM THE PERSPECTIVE OF MEDICAL EMERGENCY” Cardiovascular disease is the leading cause of death in industrialized countries has traditionally been considered a predominantly male disease. Women with cardiovascular disease had always been treated in the image of men, but in recent years several studies have shown the existence of significant differences in the physiopathology of the disease and the response to treatment and the professional attitude to these pathologies. Many studies describe these differences in the management of cardiovascular disease more prevalent in hospitalized patients. Until now it has not been asked about whether there are differences at the level of emergency care in emergency departments. The aim of this thesis is to determine whether there are gender differences in the treatment of four highly prevalent cardiovascular disease in Spanish emergency services: chest pain, acute coronary syndrome without ST segment elevation, heart failure and atrial fibrillation. To do this we conducted 4 separate studies in which different population samples were taken for Spanish emergency departments. In general, women were older and had more comorbidity, were more hypertensive, more diabetic and higher prevalence of valvular disease, while men more often had a history of ischemic heart disease and smoking. In view of the results we can conclude that there are, broadly speaking, differences in the initial treatment of these four diseases in the Spanish hospital emergency departments. Although we found variations for some subset of patients and pathology in particular, it seems that these differences are not based on the gender of the patient, but in different clinical profile presented.

Introduction: More than half of all patients seeking care for chest pain do not have a cardiac cause for this pain. Despite recurrent episodes of chest pain, many patients are discharged without a clear explanation of the cause for their pain. A lack of explanation may result in a misinterpretation of the pain as being cardiac-related, causing worry and uncertainty, which in turn leads to substantial use of healthcare resources. Psychological distress has been associated with non-cardiac chest pain (NCCP), but there is limited research regarding the relationship between different psychological factors and their association with healthcare utilization. There is a need for interventions to support patients to manage their chest pain, decrease psychological distress, and reduce healthcare utilization and costs. Aim: The overall aim of this thesis was to improve care for patients with  non-cardiac chest pain by describing related psychological distress, healthcare utilization and societal costs, and by evaluating an Internet-delivered cognitive behavioural intervention. Designs and methods: This thesis presents results from four quantitative studies. Studies I and II had a longitudinal descriptive and comparative design. The studies used the same initial cohort. Patients were consecutively approached within 2 weeks from the day of discharge from a general hospital in southeast Sweden. In study I, 267 patients participated (131 with NCCP, 66 with acute myocardial infarction (AMI), and 70 with angina pectoris (AP)). Out of these, 199 patients (99 with NCCP, 51 with AMI, 49 with AP) participated in study II. Participants were predominantly male (about 60 %) with a mean age of 67 years. Data was collected on depressive symptoms (Study I), healthcare utilization (Study I, II), and societal costs (Study II). Study III had a cross-sectional explorative and descriptive design. Data was collected consecutively on depressive symptoms, cardiac anxiety and fear of body sensations in 552 patients discharged with diagnoses of NCCP (51 % women, mean age 64 years) from four hospitals in southeast Sweden. Patients were approached within one month from the day of discharge. Study IV was a pilot randomized controlled study including nine men and six women with a median age of 66 years, who were randomly assigned to an intervention (n=7) or control group (n=8). The intervention consisted of a four-session guided Internet-delivered cognitive behavioural therapy (CBT) program containing psychoeducation, exposure to physical activity, and relaxation. The control group received usual care. Data was collected on chest pain frequency, cardiac anxiety, fear of body sensations, and depressive symptoms. Results: Depressive symptoms were prevalent in 20 % (Study IV) and 25 % (Study I, III) of the patients, and more than half of the patients still experienced depressive symptoms one year later (Study I). There were no significant differences in prevalence and severity of depressive symptoms between patients diagnosed with NCCP, AMI or AP. Living alone and younger age were independently related to more depressive symptoms (Study I). Cardiac anxiety was reported by 42 % of the patients in study III and 67 % of the patients in study IV. Fear of body sensations was reported by 62 % of the patients in study III and 93 % of the patients in study IV. On average, patients with NCCP had 54 contacts with primary care or the outpatient clinic per patient during the two-year study period. This was comparable to the number of contacts among patients with AMI (50 contacts) and AP (65). Patients with NCCP had on average 2.6 hospital admissions during the two years, compared to 3.6 for patients with AMI and 3.9 for patients with AP (Study II). Four out of ten patients reported seeking healthcare at least twice during the last year due to chest pain (Study III). On average, 14 % of patients with NCCP were on sick-leave annually, compared to 18 % for patient with AMI and 25 % for patient with AP. About 11-12 % in each group received a disability pension. The mean annual societal costs for patients with NCCP, AMI and AP were €10,068, €15,989 and €14,737 (Study II). Depressive symptoms (Study I, III), cardiac anxiety (Study III) and fear of body sensations (Study III) were related to healthcare utilization. Cardiac anxiety was the only variable independently associated with healthcare utilization (Study III). In the intervention study (Study IV), almost all patients in both the intervention and control groups improved with regard to chest pain  frequency, cardiac anxiety, fear of body sensations, and depressive symptoms. There was no significant difference between the groups. The intervention was perceived as feasible and easy to manage, with comprehensible language, adequate and varied content, and  manageable homework assignments. Conclusions: Patients with NCCP experienced recurrent and persistent chest pain and psychological distress in terms of depressive symptoms, cardiac anxiety and fear of body sensations. The prevalence and severity of depressive symptoms in patients with NCCP did not differ from patients with AMI and patients with AP. NCCP was significantly associated with healthcare utilization and patients had similar amount of primary care and outpatient clinic contacts as patients with AMI. The estimated cumulative annual national societal cost for patients with NCCP was more than double that of patients with AMI and patients with AP, due to a larger number of patients with NCCP. Depressive symptoms, cardiac anxiety and fear of body sensations were related to increased healthcare utilization, but cardiac anxiety was the only variable independently associated with healthcare utilization. These findings imply that screening and treatment of psychological distress should be considered for implementation in the care of patients with NCCP. By reducing cardiac anxiety, patients may be better prepared to handle chest pain. A short guided Internet-delivered CBT program seems to be feasible. In the pilot study, patients improved with regard to chest pain frequency, cardiac anxiety, fear of body sensations, and depressive symptoms, but this did not differ from the patients in the control group who received usual care. Larger studies with longer follow-up are needed to evaluate both the short and long- term effects of this intervention.

Abtract Background Myocardial infarction is a critical and potentially deadly condition which requires immediate treatment in hospital. Ambulance personnel shall follow prehospital guidelines of care when examinating and treating patients with chest pain and the ambulance is equipped with ECG-monitoring for early identification of infarction in order for rapidly transport to hospital. Previous studies indicate deficiency in compliance to prehospital guidelines and patients with chest pain don´t always receive an ECG in prehospital care. A report from region Västerbotten have shown that 66,3% of patients with chest pain receive ECG in ambulance care. Aim To examine compliance to prehospital guidelines in care of patients with chest pain. Methods A retrospective medical record review (N=204). Inclusion criteria The journals that was reviewed are patients who in 2019 were cared by ambulance staff and taken to hospital as priority one with chest pain. Result The mean age of patients in this study was 70,3 year (SD+/-14,1) and the majority where men (59,3%). Most of the patients presenting with prior heart or vascular disease (67,2%). A total of 42,4% experienced secondary features such as nausea, sweating or dizziness and in 32,4% of the journals these symptoms where not documented. In ambulance 80,9% did receive ECG and 35,8% got ASA, with no significant differences between gender and time of day. Most of the patients (73,5%) required pain relief one or several times during ambulance transport and 21,6% of the patients experienced pain but didn't receive treatment. Conclusion This study indicates that not all patients with chest pain get treated by the prehospital guidelines. Not every patient received an ECG and few patients received ASA. Lack of documentation regarding patients exhibited symptoms and reasons for not treating pain were found in the journals. In summary these deficiencies can negatively affect patient safety, cause medical hazards and increase health care costs.Keywords: Prehospital care, prehospital guideline of care, chest pain, myocardial infarction, ECG