The conundrum of acute chest pain in general practice: a nationwide survey in The Netherlands

Background: GPs are frequently confronted with patients with acute onset chest pain. Although usually benign, approximately 5% is due to acute coronary syndrome (ACS). Unfortunately, ACS is not always recognised, leading to a missed diagnosis in 2-5% of presentations.

Aim: The authors set out to study the level of risk GPs are willing to accept with regards to missing an ACS diagnosis, and the receptiveness of implementing new clinical decision aids.

Design & setting: This study involved an online survey among GPs in the Netherlands.

Method: A concept survey was constructed, which was tested among a panel of 24 GPs. The survey was then modified to achieve content validity. This survey was electronically distributed among 1000 GPs.

Results: A total of 313 (31.3%) GPs completed the survey. Of those surveyed, the median age was 50 years (interquartile range 41-57), 53.0% were female, and 6.4% were specialist GPs ('kaderarts') in cardiology or acute care. GPs estimated the missed ACS rate to be <5.0% in clinical practice, most often estimating a chance of 1.0-2.5% (35.2%) or 0.5-1.0% (29.7%). For atypical case presentations, 70% of GPs would accept a 0.1-1.0% missed diagnosis rate, while keeping the referral threshold to a maximum of 50 unnecessary referrals for each ACS case (75% of responders). GPs would welcome additional decision aids, with 79.2% favouring a clinical decision aid, 77.1% favouring troponin point-of-care (POC) testing, and 85.5% favoring a combination of a clinical decision aid and a troponin POC test.

Conclusion: GPs perceive that they miss more ACS cases than they feel comfortable with, which is reflected in a defensive referral strategy. The vast majority of GPs would welcome the use of clinical decision aids and/or cardiac biomarker POC testing for ruling out ACS, if accompanied by more certainty than based on clinical judgment alone.