SpringerLink
Log in

DEGAM-Leitlinie Nr. 15: Brustschmerz

DEGAM-Guideline Number 15: Chest Pain in Primary Care

  • Leitlinie
  • Published:
Zeitschrift für Allgemeinmedizin Aims and scope Submit manuscript

Zusammenfassung

Einführung

Brustschmerz ist ein häufiger Beratungsanlass in der hausärztlichen Praxis. Die Ursachen unterscheiden sich hinsichtlich Häufigkeit, Bedrohlichkeit und der zu ergreifenden diagnostischen und therapeutischen Maßnahmen. Basierend auf Anamnese und Befund formulieren Hausärzte Verdachtsdiagnosen und entscheiden über Notwendigkeit und Art der weiterführenden Diagnostik. Bisherige Leitlinien konzentrieren sich auf weiterführende Diagnostik bei einer konkreten Verdachtsdiagnose. Die ersten Schritte in der diagnostischen Kette, d.h. Anamnese und Befund, werden jedoch meist vernachlässigt. Ziel dieser Leitlinie ist es, Hausärzten evidenzbasierte Empfehlungen vor allem für die initiale klinische Einschätzung von Patienten mit Brustschmerz zu geben.

Methoden

Die Erstellung der Leitlinie erfolgte gemäß dem 10-Stufenplan der DEGAM, der die Leitlinienentwicklung auf Grundlage systematischer Literaturanalysen zu relevanten Fragestellungen, eine strukturierte Kommentierung durch Allgemeinärzte aus Praxis, Lehre und Forschung, die Konsentierung mit anderen medizinischen Fachgesellschaften und eine Praxisevaluation vorsieht.

Ergebnisse

Im Kern gibt die Leitlinie evidenzbasierte Empfehlungen, welche Ergebnisse aus Anamnese und Befund hilfreich sind, die Wahrscheinlichkeit der in Frage kommenden Ursachen des Brustschmerzes abzuschätzen bzw. Verdachtsdiagnosen zu formulieren. Empfehlungen zur spezifischen Diagnostik bzw. zur Therapie finden sich nur in Einzelfällen.

Summary

Introduction:

Chest pain is a frequent complaint in primary care. Aetiologies differ with regard to frequency, prognosis and management. Based on the history and physical examination, family practitioners (FPs) determine an initial diagnosis and decide if and which further investigations are necessary. Previous guidelines have emphasized laboratory tests and imaging; the patient’s history, physical examination and first impressions in primary care have often been neglected. This guideline gives evidence based recommendations for the early phase of the diagnostic process of patients presenting with chest pains in primary care.

Methods:

The guideline was developed and evaluated according to the standard of the German College of General Practitioners and Family Physicians (DEGAM). This standard includes systematic reviews of the literature for relevant topics, a structured review by FPs in academia and/or practice and a systematic practice based evaluation of the guideline in clinical practice.

Results:

The guideline gives evidence-based recommendations which clinical findings are helpful in the initial evaluation of patients with chest pains. We consider further investigations and therapeutic interventions only in special situations.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price includes VAT (Germany)

Instant access to the full article PDF.

Institutional subscriptions

Literatur

  1. Bösner S, Becker A, Haasenritter J et al. Chest pain in primary care: epidemiology and pre-work-up probabilities. Eur J Gen Pract 2009; 15: 141–146

    Article  PubMed  Google Scholar 

  2. Gerlach FM, Abholz H-H, Berndt M et al. Konzept zur Entwicklung, Verbreitung, Implementierung und Evaluation von Leitlinien für die hausärztliche Praxis. http://leitlinien.degam.de/index.php?id=konzeptderleitlinienent-wicklung. (zuletzt abgerufen am:10.12.2010)

  3. Scholz M, Wegener K, Unverdorben M, Klepzig H. [Long-term outcome in patients with angina-like chest pain and normal coronary angiograms]. Herz 2003; 28: 413–420

    Article  PubMed  Google Scholar 

  4. Voelker W, Euchner U, Dittmann H, Karsch KR. Long-term clinical course of patients with angina and angiographically normal coronary arteries. Clin Cardiol 1991; 14: 307–311

    Article  CAS  PubMed  Google Scholar 

  5. Papanicolaou MN, Califf RM, Hlatky MA et al. Prognostic implications of angiographically normal and insignificantly narrowed coronary arteries. Am J Cardiol 1986; 58: 1181–1187

    Article  CAS  PubMed  Google Scholar 

  6. Ladwig KH, Hoberg E, Busch R. Psychische Komorbidität bei Patienten mit alarmierender Brust-Schmerzsymptomatik. Psychother Psychosom Med Psychol 1998; 48: 46–54

    CAS  PubMed  Google Scholar 

  7. Epstein RM, Hadee T, Carroll J, Meldrum SC, Lardner J, Shields CG. „Could this be something serious?“ Reassurance, uncertainty, and empathy in response to patients’ expressions of worry. J Gen Intern Med 2007; 22: 1731–1739

    Article  PubMed  PubMed Central  Google Scholar 

  8. Mayou R, Bryant B, Forfar C, Clark D. Non-cardiac chest pain and benign palpitations in the cardiac clinic. Br Heart J 1994; 72: 548–553

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  9. Donner-Banzhoff N, Popert U, Beyer M, Rönsber W, Gerlach F. Brustschmerz. In: Kochen MM (ed.): Allgemeinmedizin und Familienmedizin: Duale Reihe. Stuttgart: Thieme-Verlag, 2006: 298–306

    Google Scholar 

  10. Howard LM, Wessely S. Reappraising reassurance – the role of investigations. J Psychosom Res 1996; 41: 307–311

    Article  CAS  PubMed  Google Scholar 

  11. Sox HC, Jr., Margulies I, Sox CH. Psychologically mediated effects of diagnostic tests. Ann Intern Med 1981; 95: 680–685

    Article  PubMed  Google Scholar 

  12. Mushlin AI, Kern LM, Paris M, Lambert DR, Williams G. The value of diagnostic information to patients with chest pain suggestive of coronary artery disease. Med Decis Making 2005; 25: 149–157

    Article  PubMed  Google Scholar 

  13. Channer KS, James MA, Papouchado M, Rees JR. Failure of a negative exercise test to reassure patients with chest pain. Q J Med 1987; 63: 315–322

    CAS  PubMed  Google Scholar 

  14. Goodacre S, Mason S, Arnold J, Angelini K. Psychologic morbidity and healthrelated quality of life of patients assessed in a chest pain observation unit. Ann Emerg Med 2001; 38: 369–376

    Article  CAS  PubMed  Google Scholar 

  15. Potts SG, Bass CM. Psychosocial outcome and use of medical resources in patients with chest pain and normal or near-normal coronary arteries: a long-term follow-up study. Q J Med 1993; 86: 583–593

    CAS  PubMed  Google Scholar 

  16. Verdon F, Herzig L, Burnand B et al. Chest pain in daily practice: occurrence, causes and management. Swiss Med Weekly 2008; 138: 340–7

    Google Scholar 

  17. Cooper A, Calvert N, Skinner J et al. Chest pain of recent onset: Assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin. http://www.nice.org.uk/nicemedia/live/12947/47931/47931.pdf. 2010. National Clinical Guideline Centre for Acute and Chronic Conditions(zuletzt abgerufen am: 05.07.2010)

  18. Bruyninckx R, Aertgeerts B, Bruyninckx P, Buntinx F. Signs and symptoms in diagnosing acute myocardial infarction and acute coronary syndrome: a diagnostic meta-analysis. Br J Gen Pract 2008; 58: 105–111

    Article  PubMed  Google Scholar 

  19. Chun AA, McGee SR. Bedside diagnosis of coronary artery disease: a systematic review. Am J Med 2004; 117: 334–343

    Article  PubMed  Google Scholar 

  20. Mant J, McManus RJ, Oakes RA et al. Systematic review and modelling of the investigation of acute and chronic chest pain presenting in primary care. Health Technol Assess 2004; 8: iii, 1–iii158

    Google Scholar 

  21. DEGAM-Leitlinie Brustschmerz – Methoden- und Evidenzreport. 2011. Verfügbar unter: http://leitlinien.degam.de/

  22. Bösner S, Becker A, Abu HM et al. Accuracy of symptoms and signs for coronary heart disease assessed in primary care. Br J Gen Pract 2010; 60: 246–257

    Article  Google Scholar 

  23. Gencer B, Vaucher P, Herzig L et al. Ruling out coronary heart disease in primary care patients with chest pain: a clinical prediction score. BMC Med 2010; 8: 9

    Article  PubMed  PubMed Central  Google Scholar 

  24. Bösner S, Haasenritter J, Becker A et al. Ruling out coronary artery disease in primary care: development and validation of a simple prediction rule. CMAJ 2010

  25. Luiz T, Ellinger K, Budde A, Hechler C, Klar H, Riester T. [Evaluation of a rapid qualitative test for cardiac troponin T in clinical diagnosis of patients with acute coronary syndrome]. Z Kardiol 1998; 87: 267–275

    Article  CAS  PubMed  Google Scholar 

  26. Planer D, Leibowitz D, Paltiel O, Boukhobza R, Lotan C, Weiss TA. The diagnostic value of troponin T testing in the community setting. Int J Cardiol 2006; 107: 369–375

    Article  PubMed  Google Scholar 

  27. Ecollan P, Collet JP, Boon G et al. Pre-hospital detection of acute myocardial infarction with ultra-rapid human fatty acid-binding protein (H-FABP) immunoassay. Int J Cardiol 2007; 119: 349–354

    Article  PubMed  Google Scholar 

  28. Scottish Intercollegiate Guidelines Network. Acute Coronary Syndromes – A National clinical guideline. http://www.sign.ac.uk/pdf/sign93.pdf. 2007. Scottish Intercollegiate Guidelines Network (zuletzt abgerufen am: 11.10.2009)

  29. Guidelines for the management of acute coronary syndromes 2006. Med J Aust 2006; 184: S9–29

  30. Bassand JP, Hamm CW, Ardissino D et al. Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes. Eur Heart J 2007; 28: 1598–1660

    Article  CAS  PubMed  Google Scholar 

  31. Rosser W, Henderson R, Wood M, Green L. An exploratory report of chest pain in primary care. A report from ASPN. J Am Board Fam Pract 1990; 3: 143–150

    Google Scholar 

  32. Klinkman MS, Stevens D, Gorenflo DW. Episodes of care for chest pain: a preliminary report from MIRNET. Michigan Research Network. J Fam Pract 1994; 38: 345–352

    CAS  PubMed  Google Scholar 

  33. Buntinx F, Knockaert D, Bruyninckx R et al. Chest pain in general practice or in the hospital emergency department: is it the same? Fam Pract 2001; 18: 586–589

    Article  CAS  PubMed  Google Scholar 

  34. Nilsson S, Scheike M, Engblom D et al. Chest pain and ischaemic heart disease in primary care. Br J Gen Pract 2003; 53: 378–382

    CAS  PubMed  PubMed Central  Google Scholar 

  35. Huffman JC, Pollack MH, Stern TA. Panic disorder and chest pain: mechanisms, morbidity, and management. J Clin Psychiatry 2002; 4: 5462

    Google Scholar 

  36. Huffman JC, Pollack MH. Predicting panic disorder among patients with chest pain: an analysis of the literature. Psychosomatics 2003; 44: 222–236

    Article  PubMed  Google Scholar 

  37. Verdon F, Burnand B, Herzig L, Junod M, Pecoud A, Favrat B. Chest wall syndrome among primary care patients: a cohort study. BMC Fam Pract 2007; 8: 51

    Article  PubMed  PubMed Central  Google Scholar 

  38. Bösner S, Becker A, Hani MA et al. Chest wall syndrome in primary care patients with chest pain: presentation, associated features and diagnosis. Fam Pract 2010

  39. Wehrmacher HW. The painful anterior chest wall syndromes. Med Clin North Am 1958; 42: 111–118

    Article  CAS  PubMed  Google Scholar 

  40. Wise CM. Chest wall syndromes. Curr Opin Rheumatol 1994; 6: 197–202

    Article  CAS  PubMed  Google Scholar 

  41. Fam AG. Approach to musculoskeletal chest wall pain. Prim Care 1988; 15:767–782

    Article  CAS  PubMed  Google Scholar 

  42. Kalke S, Perera SD, Patel ND, Gordon TE, Dasgupta B, Wise CM. The sternoclavicular syndrome: experience from a district general hospital and results of a national postal survey. Rheumatology 2001; 40: 170–177

    Article  CAS  PubMed  Google Scholar 

  43. Heinz GJ, Zavala DC. Slip** rib syndrome. JAMA 1977; 237: 794–795

    Article  CAS  PubMed  Google Scholar 

  44. Arroyo JF, Jolliet P, Junod AF. Costovertebral joint dysfunction: another misdiagnosed cause of atypical chest pain. Postgrad Med J 1992; 68: 655–659

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  45. Wang WH, Huang JQ, Zheng GF et al. Is proton pump inhibitor testing an effective approach to diagnose gastroesophageal reflux disease in patients with noncardiac chest pain?: a meta-analysis. Arch Intern Med 2005; 165: 1222–1228

    Article  CAS  PubMed  Google Scholar 

  46. Cremonini F, Wise J, Moayyedi P, Talley NJ. Diagnostic and therapeutic use of proton pump inhibitors in non-cardiac chest pain: a metaanalysis. Am J Gastroenterol 2005; 100: 1226–1232

    Article  CAS  PubMed  Google Scholar 

  47. Fass R, Dickman R. Non-cardiac chest pain: an update. Neurogastroenterol Motil 2006; 18: 408–417

    Article  CAS  PubMed  Google Scholar 

  48. Fass R, Fennerty MB, Ofman JJ et al. The clinical and economic value of a short course of omeprazole in patients with noncardiac chest pain. Gastroenterology 1998; 115: 42–49

    Article  CAS  PubMed  Google Scholar 

  49. Borzecki AM, Pedrosa MC, Prashker MJ. Should noncardiac chest pain be treated empirically? A cost-effectiveness analysis. Arch Intern Med 2000; 160: 844–852

    Article  CAS  PubMed  Google Scholar 

  50. Kachintorn U. How do we define non-cardiac chest pain? J Gastroenterol Hepatol 2005; 20 Suppl: S2–S5

    Article  PubMed  Google Scholar 

  51. Gasiorowska A, Fass R. The proton pump inhibitor (PPI) test in GERD: does it still have a role? J Clin Gastroenterol 2008; 42: 867–874

    Article  CAS  PubMed  Google Scholar 

  52. Katz PO. Noncardiac chest pain. Rev Cardiovasc Med 2005; 6 Suppl 4: S32–S39

    Google Scholar 

  53. Wong WM, Fass R. Extraesophageal and atypical manifestations of GERD. J Gastroenterol Hepatol 2004; 19 Suppl 3: S33–S43

    Article  Google Scholar 

  54. Talley NJ. American Gastroenterological Association medical position statement: evaluation of dyspepsia. Gastro-enterology 2005; 129: 1753–1755

    Article  Google Scholar 

  55. Ford AC, Moayyedi P. Current guidelines for dyspepsia management. Dig Dis 2008; 26: 225–230

    Article  PubMed  Google Scholar 

  56. McGee S. Evidence based physical diagnosis. 2nd ed. St. Louis: Saunders Elsevier, 2007

  57. Graffelman AW, le Cessie S, Knuistingh NA, Wilemssen FE, Zonderland HM, van den Broek PJ. Can history and exam alone reliably predict pneumonia? J Fam Pract 2007; 56: 465–470

    CAS  PubMed  Google Scholar 

  58. Melbye H, Straume B, Aasebo U, Brox J. The diagnosis of adult pneumonia in general practice. The diagnostic value of history, physical examination and some blood tests. Scand J Prim Health Care 1988; 6: 111–117

    Article  CAS  PubMed  Google Scholar 

  59. Hopstaken RM, Muris JW, Knottnerus JA, Kester AD, Rinkens PE, Dinant GJ. Contributions of symptoms, signs, erythrocyte sedimentation rate, and C-reactive protein to a diagnosis of pneumonia in acute lower respiratory tract infection. Br J Gen Pract 2003; 53: 358–364

    CAS  PubMed  PubMed Central  Google Scholar 

  60. van der Does E., Lubsen J, Pool J. Acute myocardial infarction: an easy diagnosis in general practice? J R Coll Gen Pract 1980; 30: 405–409

    PubMed  PubMed Central  Google Scholar 

  61. Stein MB, Roy-Byrne PP, McQuaid JR et al. Development of a brief diagnostic screen for panic disorder in primary care. Psychosom Med 1999; 61: 359–364

    Article  CAS  PubMed  Google Scholar 

  62. Kroenke K, Spitzer RL, Williams JB, Monahan PO, Lowe B. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med 2007; 146: 317–325

    Article  PubMed  Google Scholar 

  63. Arroll B, Khin N, Kerse N. Screening for depression in primary care with two verbally asked questions: cross sectional study. BMJ 2003; 327: 1144–1146

    Article  PubMed  PubMed Central  Google Scholar 

  64. Whooley MA, Avins AL, Miranda J, Browner WS. Case-finding instruments for depression. Two questions are as good as many. J Gen Intern Med 1997; 12: 439–445

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  65. Albus C, Herrmann-Lingen C. Funktionelle Störungen in der Kardiologie. Psychosomatik und Konsiliarpsychiatrie 2007; 1: 118–122

    Article  Google Scholar 

  66. Bösner S, Haasenritter J, Becker A et al. Heartburn or angina? Differentiating gastrointestinal disease in primary care patients presenting with chest pain: a cross sectional diagnostic study. Int Arch Med 2009; 2: 40

    Article  PubMed  PubMed Central  Google Scholar 

  67. Davies HA, Jones DB, Rhodes J, Newcombe RG. Angina-like esophageal pain: differentiation from cardiac pain by history. J Clin Gastroenterol 1985; 7: 477–481

    Article  CAS  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Abteilung für Allgemeinmedizin, Präventive und Rehabilitative Medizin, Universität Marburg, Karl-von-Frisch-Str. 4, 35043, Marburg, Deutschland

    Jörg Haasenritter MScN,  Stefan Bösner MPH & Norbert Donner-Banzhoff

  2. Niedergelassener Allgemeinarzt, Gilserberg, Deutschland

    Joachim Klug

  3. Abteilung Allgemeinmedizin und Versorgungsforschung, Universitätsklinikum Heidelberg, Kompetenzzentrum Allgemeinmedizin, Baden-Württemberg, Deutschland

    Thomas Ledig

Authors
  1. Jörg Haasenritter MScN
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Stefan Bösner MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Joachim Klug
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Thomas Ledig
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Norbert Donner-Banzhoff
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Jörg Haasenritter MScN.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Haasenritter, J., Bösner, S., Klug, J. et al. DEGAM-Leitlinie Nr. 15: Brustschmerz. Z Allg Med 87, 182–191 (2011). https://doi.org/10.3238/zfa.2011.0182

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.3238/zfa.2011.0182

Schlüsselwörter

Keywords (MeSH)

Search

Navigation