Suspicion Of Acute Myocardial Infarction Research Articles

Asociación del síndrome tako-tsubo con la arteria coronaria descendente anterior con extensa distribución por el segmento diafragmático

Tako-tsubo-like transient left ventricular apical ballooning has been described in Japan, but few cases have been reported in Western countries. We report one of the first series outside Japan, which provides new information on the coronary anatomy of this disorder. From January 1998 to February 2003 we observed 11 patients with a clinical suspicion of acute myocardial infarction, normal coronary arteries, and transient tako-tsubo-like systolic left ventricular apical ballooning. We compared the coronary artery anatomy in these 11 patients with that in 44 controls matched for age and sex: 22 with normal coronary arteries and 22 with acute myocardial infarction related with an obstructive thrombus in the left anterior descending coronary artery. As in Japanese patients, tako-tsubo syndrome in Caucasian patients frequently occurs in women in their seventh or eighth decades of life, and is usually preceded by emotional or physical stress. The left anterior descending in our patients with tako-tsubo syndrome was longer overall, and its recurrent diaphragmatic segment was longer, than in controls. To compare these groups we designed a measure termed recurrent segment index (left anterior descending recurrent segment length/total left anterior descending length x 100). In tako-tsubo syndrome this index was 22.3 (1.5)%, vs 10.9 (6.7)% in normal controls (P<.001), and 11.3 (7.7)% in acute myocardial infarction patients (P<.001). Patients with acute myocardial infarction and a high recurrent segment index (> or =16%) had ventriculographic findings of systolic apical ballooning identical to those in patients with tako-tsubo syndrome. All our patients with tako-tsubo syndrome had a left anterior descending with a long recurrent segment. The identical ventriculographic findings in patients with tako-tsubo syndrome and those with acute myocardial infarction with a long recurrent segment may be due to a common etiology.

Ten-year mortality for patients discharged after hospitalization for chest pain or other symptoms raising suspicion of acute myocardial infarction in relation to hospital discharge diagnosis.

To describe the 10-year prognosis for patients discharged after hospitalization for chest pain or other symptoms giving an initial suspicion of acute myocardial infarction (AMI) in relation to the final hospital diagnosis and furthermore to compare the outcome amongst these patients with the outcome amongst a sex-, age- and community-matched control population. All patients who were hospitalized because of chest pain or other symptoms raising a suspicion of AMI and who were discharged alive from hospital. Patients were divided into three groups according to the final diagnosis: (1) confirmed or possible AMI, (2) confirmed or possible myocardial ischaemia and (3) other aetiology. Information on 10-year mortality was available in 3103 patients. A sex-, age- and community-matched control population (n=3221) was compared with the study population in terms of 10-year mortality. TIME OF SURVEY: 15 February 1986 to 9 November 1987. Sahlgrenska University Hospital. Patients with confirmed or possible AMI (n=849) had a significantly higher mortality (59.4%) than patients with confirmed or possible myocardial ischaemia (n=1191) who had a mortality of 49.5% (P < 0.0001). The latter group had a higher mortality than patients with 'other aetiology' (n=1063) of whom 40.6% died (P < 0.0001). When comparing the prognosis for patients with AMI and myocardial ischaemia, there was a significant interaction with sex, with a more marked difference in women than in men. Amongst all patients, the 10-year mortality was 49.1 vs. 37.3% in the control group (P < 0.0001). The very long term prognosis was strongly associated with diagnosis amongst patients hospitalized and discharged alive because of chest pain or other symptoms raising suspicion of AMI. The absolute mortality difference between patients who were discharged from hospital with confirmed diagnosis of AMI and those whose symptoms were considered to have other aetiology than AMI or ischaemia was nearly 20%. However, the absolute mortality difference between the patients included in the survey and a control population was only 12%.

A description of the characteristics and outcome of patients hospitalized for acute chest pain in relation to whether they were admitted to the coronary care unit or not in the thrombolytic era

Objectives: To describe the characteristics and outcome of patients hospitalized for acute chest pain in relation to whether they were admitted to the coronary care unit (CCU) or not. Design: Prospective observational study with a follow-up of 2 years. Setting: Sahlgrenska University Hospital in Göteborg, Sweden. Subjects: All patients hospitalized due to acute chest pain during 6 months. Main outcome measures: Mortality, use of medical resources, complications and previous history. Results: In all 1.592 patients were admitted to hospital for chest pain, of whom 1.136 (71%) were not directly admitted to the CCU. These patients differed from those directly admitted to the CCU, being older, including more women, having a higher prevalence of known congestive heart failure and a lower degree of initial suspicion of acute myocardial infarction (AMI). Among all patients with confirmed AMI only 58% were directly admitted to CCU. Overall, the occurrence of complications and the use of medical resources were less frequent in the patients not admitted to the CCU. The mortality during the subsequent 2 years was 16.8% for patients not admitted to the CCU and 18.5% for patients admitted to the CCU. When adjusting for various factors at baseline, patients admitted to the CCU had a relative risk of death during 2 years of follow-up being 1.23 0.87–1.73 ( P=0.24) as compared with those not admitted to the CCU. Conclusion: In a Swedish university hospital, more than two thirds of patients hospitalized for acute chest pain were not directly admitted to the CCU. They differed from those admitted to the CCU in several aspects. However, their unadjusted and adjusted mortality during the subsequent 2 years did not significantly differ from those admitted to CCU.

Prognosis and risk indicators of death during a period of 10 years for women admitted to the emergency department with a suspected acute coronary syndrome

Aim: To describe the 10-year prognosis and risk indicators of death in women admitted to the emergency department with acute chest pain or other symptoms raising a suspicion of acute myocardial infarction (AMI). Particular interest was paid to women of ≤75 years of age surviving 1 month after admission, who were judged to have suffered a possible or confirmed acute ischemic event with signs of either minor or no myocardial damage. Patients: All women admitted to the emergency department at Sahlgrenska University Hospital, Göteborg, during a period of 21 months, due to acute chest pain or other symptoms raising a suspicion of AMI. Methods: All the women were followed prospectively for 10 years. The subset described previously underwent a bicycle exercise tolerance test and metabolic screening 3 and 4 weeks, respectively, after admission to the emergency department. Results: In all, 5362 patients were admitted to the emergency department on 7157 occasions during the time of the survey and 2387 (45%) of them were women. Of these women, 61% were hospitalised and 39% were sent home directly. The overall 10-year mortality for women was 42.5% (55.5% among those hospitalised and 21.8% among those not hospitalised). Of the variables recorded at the emergency department, the following were independently associated with 10-year mortality: age, history of angina pectoris, history of hypertension, history of diabetes, history of congestive heart failure, pathological ECG on admission, degree of initial suspicion of AMI on admission, symptoms of congestive heart failure on admission and other non-specific symptoms on admission. The majority of these risk factors were more markedly associated with prognosis in women discharged directly from the emergency department than in those hospitalised. In the subset aged ≤75 years defined above ( n=241), the following were independent predictors of death: a history of AMI and working capacity in a bicycle exercise tolerance test. Conclusion: Among women admitted to hospital due to chest pain or other symptoms raising a suspicion of AMI, 42.5% had died after 10 years. Major risk indicators of death were age, history of cardiovascular disease, pathological ECG on admission and symptoms of congestive heart failure on admission. Women presenting with an acute coronary syndrome but minimal myocardial damage, work capacity and a history of AMI predicted a poor outcome.

Characteristics and long-term outcome of patients with acute chest pain or other symptoms raising suspicion of acute myocardial infarction in relation to whether they were hospitalized or directly discharged from the emergency department.

To describe the characteristics and outcome of patients who came to the emergency department due to chest pain or other symptoms raising suspicion of acute myocardial infarction (AMI) in relation to whether they were hospitalized or directly discharged from the emergency department. All patients arriving to the emergency department in one single hospital due to chest pain or other symptoms raising suspicion of AMI during a period of 21 months were followed for 10 years. In all, 5362 patients fulfilled the given criteria on 7157 occasions; 3381 (63%) were hospitalized and 1981 (37%) were directly discharged. Patients who were hospitalized were older and had a higher prevalence of previous cardiovascular diseases. The mortality during the subsequent 10 years was 52.1% among those hospitalized and 22.3% among those discharged (P < 0.0001). Risk indicators for death were similar in the two cohorts. However, many of these risk indicators including age, a history of myocardial infarction, angina pectoris, congestive heart failure, hypertension, initial degree of suspicion of AMI, a pathologic electrocardiogram on admission and a confirmed AMI as underlying etiology were more strongly associated with the prognosis among patients directly discharged than among those hospitalized. Ten (0.5%) of the patients who were directly discharged from the emergency department were found to have a diagnosis of confirmed or possible AMI, making up 1% of all patients given such a diagnosis. These patients had a 10-year mortality of 80.0% compared with 65.7% among patients with a confirmed or possible AMI who were hospitalized. Of patients who came to the emergency department with acute chest pain or other symptoms suggestive of AMI about a third were directly discharged. Their mortality during the subsequent 10 years was half that of patients hospitalized. Various risk indicators for death were more strongly associated with prognosis in the patients who were directly discharged from the emergency department compared to those hospitalized. Of all patients given a diagnosis of confirmed or possible AMI, 1% were discharged from the emergency department. Their long-term mortality was high, maybe even higher than among AMI patients hospitalized.

ECG criteria in diagnosis of acute myocardial infarction in the presence of left bundle branch block

Background: The diagnosis of acute myocardial infarction in the presence of left bundle branch block is difficult. Recently a diagnostic ECG scoring system was suggested, showing good diagnostic abilities. This scoring system has never been tested in a prospective manner; we have done so and investigated if it might bear prognostic information. Methods: A prospective multi-centre study. Consecutive patients with left bundle branch block and suspicion of acute myocardial infarction, admitted to 14 Swedish coronary care units. Recruitment from March 1996 to December 1997. ECG registered on admission and after 12–24 h. Results: One hundred and fifty-eight patients were included, mean age 74.9 years. Seventy-six patients (48%) had an acute myocardial infarction. The proposed cut-off total score of ≥3 of the ECG scoring system for the diagnosis of acute myocardial infarction had a sensitivity of 17.1% (95% CI 8.6–25.6%) and specificity of 94.0% (95% CI 88.9–99.1%). Clinical judgement of acute myocardial infarction resulted in a sensitivity of 15.8% (95% CI 7.6–24%) and specificity of 96.0% (CI 92.3–100%). No difference was seen in 3-month or 1-year survival between those with total ECG score ≥3 versus total score <3. Conclusion: The diagnostic abilities of the proposed ECG criteria are low and not better than the clinical judgement. The criteria are therefore not suitable for screening patients with suspicion of acute myocardial infarction in the presence of left bundle branch block, nor do they seem to identify high risk patients.

Myocarditis in patients with clinical presentation of myocardial infarction and normal coronary angiograms

OBJECTIVESThe aim of this study was to assess the diagnosis of myocarditis in patients presenting with acute myocardial infarction (MI) and normal coronary angiograms.BACKGROUNDMost often in these patients, the etiologic diagnosis remains unclear once they are found to have normal coronary arteries. The diagnosis of myocarditis mimicking MI is clinically relevant, because numerous arguments suggest a relation between myocarditis and dilated cardiomyopathy. Myocardial indium-111 (111In)-antimyosin antibody (AMA)/rest thallium-201 (201Tl) imaging allows noninvasive detection of myocarditis.METHODSForty-five patients admitted to three intensive care units for suspicion of acute MI, with normal coronary angiograms, were investigated. Indium-111–AMA planar images and then a dual-isotope rest AMA/201Tl tomographic study were performed. Six-month echocardiographic follow-up was obtained in 80% of the patients with initial left ventricular (LV) wall motion abnormalities.RESULTSIn eight patients, AMA and 201Tl scintigraphy were negative. In two patients, a matched 201Tl defect and focal AMA uptake suggested acute MI (due to prolonged vasospasm or spontaneously reperfused coronary occlusion). In 17 patients, diffuse AMA uptake over the whole LV suggested diffuse myocarditis. In 18 patients, focal AMA uptake with a normal 201Tl scan suggested diffuse but heterogeneous, or focal myocarditis. Complete functional recovery was observed in 81% of the patients with a pattern of myocarditis.CONCLUSIONSAmong 45 patients presenting with acute MI and normal coronary angiograms, 38% had diffuse myocarditis and 40% had a scintigraphic pattern of heterogeneous or focal myocarditis. Short-term follow-up showed complete LV functional recovery in 81% of these patients.

Patients admitted to the emergency department with acute chest pain—is there a difference between patients in an urban and a rural area?

The aim of this study was to compare the characteristics and outcome for patients coming to the emergency department with acute chest pain in a city university hospital, representing an urban area, and a county hospital, representing a rural area. This was a retrospective survey of all chest pain patients at Sahlgrenska University Hospital, Göteborg, covering an area with 706 inhabitants/km2, and at Uddevalla County Hospital, Uddevalla, covering an area with 34 inhabitants/km2, over a period of 6 months. In all 2,297 patients were registered at Sahlgrenska University Hospital and 1062 at Uddevalla Hospital (per 100,000 inhabitants and year 1,502 and 1,342 patients, respectively). The patients in the urban area were more frequently sent home from the emergency department than in the rural area (30% versus 23%; p < 0.0001). Patients in the urban area had a lower prevalence of previous cardiovascular diseases. An obvious acute myocardial infarction (AMI) or a strong suspicion of AMI at initial evaluation was less frequent in the urban area whereas no suspicion of AMI was twice as common (46% versus 24%; p < 0.0001). Furthermore, there was a difference in the use of medications; various cardiovascular drugs were more frequently used in the rural area. Despite these differences at baseline the 30-day mortality was similar (3.5% in the urban area and 3.6% in the rural area; NS), as well as the 2-year mortality (14.0% and 12.7%, respectively; NS). It is concluded that the number of patients admitted to the emergency department with acute chest pain/100,000 was slightly higher in the urban than in the rural area. Patients in the urban area differed from those in the rural area having a lower prevalence of previous cardiovascular diseases, a lower initial suspicion of AMI, they were less frequently hospitalized and less frequently prescribed various cardiovascular drugs. Mortality did not differ between the two cohorts.

Bundle Branch Block and Acute Myocardial Infarction: Treatment and Outcome

Objective - To study early diagnosis, treatment and outcome in patients with bundle branch block and clinically suspected acute myocardial infarction. Design - A prospective multicenter study including 14 Swedish coronary care units. The study included 257 consecutive patients with bundle branch block and clinical suspicion of acute myocardial infarction. Results - Left bundle branch block was present in 62% of patients and right bundle branch block in 38%. Thrombolytic treatment of acute myocardial infarction in the left and right bundle branch block was 16% and 36%, respectively. Of those undergoing thrombolytic therapy, 20% of patients with left and 13% with right bundle branch block did not develop an acute myocardial infarction. Patients with left bundle branch block had higher mortality rates than those with right bundle branch block. After one year there was no difference in mortality rates between patients with and those without acute myocardial infarction on admission. Conclusion - Patients with bundle branch block and suspected acute myocardial infarction receive suboptimal treatment. Thus better diagnostic regimes are needed to identify those patients with bundle branch block and acute myocardial infarction who are suitable for thrombolytic treatment.

Morphine use and pharmacokinetics in patients with chest pain due to suspected or definite acute myocardial infarction

The characteristics of chest pain due to suspected acute myocardial infarction and morphine use during the first 3 hospital days are described in a population of 2988 consecutive patients admitted to hospital. The duration of pain was usually less than 24h (mean 20.9±0.55h), and only 24.8% of patients experienced chest pain of longer duration. The majority of patients had only one attack of pain, but 34.4% experienced four or more attacks during hospitalization. A mean morphine dose of 6.7±0.2mg was administered over the 3 hospitalization days, but surprisingly 52.4% of all patients required no morphine analgesia at all. Independent predictors of an increased morphine consumption were initial degree of suspicion of acute myocardial infarction, ST changes on admission ECG, male sex, a history of angina pectoris and a history of congestive heart failure. In a separate pharmacokinetic/pharmacodynamic study in 10 patients, plasma concentrations of morphine and its major metabolites, morphine-3-glucuronide (M3G) and morphine-6-glucuronide (M6G), were measured after intravenous administration of morphine. In this patient group, terminal half-life of unchanged morphine ranged from 0.77 to 3.22h. M3G and M6G plasma concentrations increased gradually up to 60–90 min after the intravenous morphine injection. Initial pain intensity by numerical rating scale was 6.6±0.6 (arbitrary units), and after morphine administration, there was a rapid and significant decrease in pain intensity. After 20 min, pain relief was 69±11% and remained at this level during the following 8 h observation period. It is concluded that the need for morphine administration in patients with suspected or definite acute myocardial infarction, differs among subgroups of patients and, in particular, higher doses are needed in those with a strong suspicion of myocardial infarction at arrival. When intravenous morphine is given, it attains full effect 20 min after injection. Furthermore, the active morphine metabolites M3G and M6G appear rapidly in thecirculation, which could influence the analgesic response to morphine treatment.

Predictors of outpatient cardiac rehabilitation utilization: the Minnesota Heart Surgery Registry.

A significant proportion of eligible patients do not participate in cardiac rehabilitation. The purpose of this study was to document patterns of outpatient cardiac rehabilitation use and identify factors predicting its use. The Acute Myocardial Infarction Registry of the Minnesota Heart Survey enrolled 3,841 patients admitted on suspicion of acute myocardial infarction (MI) to the coronary care units at six Minneapolis-St. Paul metropolitan hospitals. Participants were contacted 1 year after index hospitalization and asked if they participated in cardiac rehabilitation since discharge. Among those discharged with a MI, 47% participated in outpatient cardiac rehabilitation or an exercise program at an exercise facility, home, or both during the 1-year follow-up period. Among those discharged with angina, 21% attended cardiac rehabilitation. Usage increased when cardiac revascularization procedures were performed during the index hospitalization. Women with an angina or MI diagnosis were significantly less likely to use cardiac rehabilitation than men. Older patients were also less likely to use rehabilitation, with gender difference persisting across age strata. As education increased, cardiac rehabilitation utilization increased. Those not employed were less likely to use cardiac rehabilitation services. The strongest independent predictors of cardiac rehabilitation utilization were age and revascularization procedures (coronary artery bypass grafting or coronary angioplasty), simultaneously adjusting for demographic information, and cardiovascular disease risk factors. These data suggest that there is a disparity in cardiac rehabilitation utilization with lower rates among women, older individuals, those with less education, and the unemployed.

Impact of a chest pain clinic on recurrency of symptoms and readmissions among patients early discharged from hospital after acute myocardial infarction was ruled out

This paper evaluates the impact of an early revisit including symptom evaluation and an exercise electrocardiogram on recurrency of symptoms and readmissions during 1 year of follow-up among patients coming to hospital with chest pain or an initial suspicion of acute myocardial infarction (AMI) but in whom the suspicion was quickly ruled out. Patients below the age of 65 admitted to the emergency department (ED) at Sahlgrenska Hospital due to chest pain or other symptoms raising a suspicion of AMI who were either directly discharged from the ED or discharged within 1 day after having AMI ruled out. Patients were allocated to two groups: (1) patients being re-evaluated in a chest pain clinic less than a week after discharge from hospital (intervention group) and (2) patients handled routinely with no formalized follow-up (control group). The intervention group (n=484) and the control group (n=374) were comparable at baseline. During 1 year of follow-up, patients in the intervention group had a lower rate of readmissions to the ED than patients in the control group (17.4% versus 24.9%, p < 0.05) and a lower rate of rehospitalizations (15.9% versus 23.3%, p < 0.05). The proportion of patients being on sick leave at any time during the follow-up did not differ and neither did the recurrency of symptoms. The introduction of a chest pain clinic for patients early discharged from hospital after having AMI ruled out indicated beneficiency in terms of a lower rate of readmissions to the ED and a lower requirement of rehospitalizations. However, a methodological weakness in the randomization procedure suggest carefulness in interpretation.

Predictors and mode of death over 5 years amongst patients admitted to the emergency department with acute chest pain or other symptoms raising suspicion of acute myocardial infarction.

To describe the mortality and mode of death over 5 years, and factors associated with death amongst patients with acute chest pain. All patients who came to the emergency department at Sahlgrenska Hospital in Göteborg with acute chest pain or other symptoms raising suspicion of acute myocardial infarction (AMI) during a 21-month period. In all, 5241 patients were evaluated, of whom 1345 (26%) died during the 5 years of follow-up. The following factors were independent predictors male sex (P < 0.001); symptoms of acute congestive heart failure (P < 0.001) or unspecific symptoms on admission (P < 0.05); smoking (P < 0.001); a history of either congestive heart failure (P < 0.001), diabetes mellitus (P < 0.001), previous myocardial infarction (P < 0.001) or hypertension (P < 0.05); initial degree of suspicion of AMI (P < 0.001) and presence of pathological electrocardiogram (P < 0.001) on admission to hospital. Amongst patients who died, 66% died a cardiac death and 35% died in association with a myocardial infarction. Amongst patients admitted to the emergency department due to chest pain or other symptoms raising suspicion of AMI, several predictors based on clinical history and clinical presentation can be defined, which are strongly related to the long-term prognosis.

Prognosis During Five Years of Follow-up Among Patients Admitted to the Emergency Department with Acute Chest Pain in Relation to a History of Hypertension

Aim: To describe the mortality, mode and place of death and risk indicators of death during 5 years of follow-up among patients admitted to the emergency department (ED) with acute chest pain or other symptoms raising a suspicion of acute myocardial infarction (AMI) in relation to a history of hypertension. Methods: All the patients admitted to the ED at Sahlgrenska University Hospital during a period of 21 months with acute chest pain or other symptoms raising a suspicion of AMI were followed up prospectively for 5 years. Results: Of 5,355 patients fulfilling the inclusion criteria, 22% had a history of hypertension. Hypertensive patients differed from non-hypertensive patients in that there were more females, they were older and had a higher prevalence of previous cardiovascular disease. Patients with a history of hypertension had a 5-year mortality rate of 37.4% as compared with 22.2% among non-hypertensive patients (p < 0.001). The difference in mortality appeared to be more marked among patients without a history of cardiovascular disease. A history of hypertension was an independent predictor of death. Risk indicators of death appeared to be relatively similar among patients with and without a history of hypertension. Of the patients who died, those with a history of hypertension were more frequently judged to have suffered a cardiac death and died more frequently in association with an AMI. Conclusion: Among patients admitted to the ED with acute chest pain and with a history of hypertension, 37% died during the following 5 years. A history of hypertension was an independent predictor of death.

Long-term prognosis in men and women coming to the emergency department with chest pain or other symptoms suggestive of acute myocardial infarction

The aim of this study was to describe mortality, mode of death and risk indicators for death during 5 years of follow-up among men and women coming to the emergency department with chest pain or other symptoms raising suspicion of acute myocardial infarction (AMI). During the 21 months of the study, all patients who came to the medical emergency department of one single hospital with chest pain or other symptoms suggestive of AMI were prospectively followed for 5 years. A total of 5362 patients came on 7157 occasions; men accounted for 55% of the admissions. The 5-year mortality rate was 25.6% for men compared with 25.7% for women. The women were older and had a higher prevalence of known congestive heart failure and hypertension, whereas the prevalence of previous myocardial infarction was higher in men. When correcting for dissimilarities in age and clinical history, male gender appeared as an independent predictor of death. In terms of mode of death men differed from women: more frequently dying at home, more frequently dying in association with ventricular fibrillation and less frequently dying in association with congestive heart failure. However, these differences were to some extent explained by differences in age. Independent risk indicators for death during 5 years of follow-up differed in men and women. It was concluded that in a consecutive series of patients with chest pain or other symptoms suggesting AMI in the emergency department, male gender was an independent risk indicator for death during a 5-year follow-up. This might be explained by a higher occurrence of coronary artery disease in men than in women in this patient population.

Regional differences in hospital admission rates for suspected and verified myocardial infarction in Nord-Tr$oSndelag county, Norway

Objective - To investigate differences in the occurrences of hospitalized suspected and verified acute myocardial infarction (AMI) between the two hospital regions, Namdal and Innherred, within a single county in Norway.Design - A descriptive epidemiological study.Setting - The county of Nord-Tr0ndelag in the central part of Norway (131000 inhabitants).Subjects - Patients admitted for suspected AMI 13 March - 11 June 1995.Main outcome measures - Proportion of verified AMI among patients admitted. Regional incidence rates for AMI.Results - Among 347 patients admitted to hospitals with suspected AMI, AMI was verified in 120 (35%), corresponding to an annual incidence rate of 509 and 294 per 100000 (p>0.001).Conclusions - Among patients admitted with suspicion of AMI, approximately one third had AMI. The study revealed substantial differences for AMI between two neighbouring hospital regions within one county in Norway. This difference may have implications for the planning and cost of hospital care.

Improvement of ED prediction of cardiac mortality among patients with symptoms suggestive of acute myocardial infarction

A study was undertaken to evaluate the 1-year risk of cardiac death for patients with chest pain/suspected acute myocardial infarction in the emergency department (ED) and express the prognosis in a statistical model. Clinical variables and electrocardiogram were correlated to cardiac death during 1 year. Cox regression model was used to estimate the risk of death as a continuous function of a risk score and the time interval. From these, the prognosis for each patient can be calculated. There were 6,794 visits by 5,303 patients followed for 1 year, during which 604 patients died. The absolute risk of cardiac death can be calculated from the independent predictors for cardiac death: age; sex; histories of diabetes mellitus, hypertension, and congestive heart failure; and symptoms, electrocardiographic pattern, and degree of suspicion of acute myocardial infarction on admission. This model allows estimation of the prognosis for every patient with chest pain/suspected acute myocardial infarction from data easily available in the ED.

Cost-Effectiveness of Mandatory Stress Testing in Chest Pain Center Patients

See related editorial, p 168. Study objective: To determine whether emergency patients with acute chest pain and low suspicion of acute myocardial infarction (AMI) can be managed cost-effectively and safely in a dedicated chest pain center (CPC) that incorporates mandatory stress testing. Methods: We assembled a prospective observational case series of consecutive adult patients transferred from the emergency department to a nine-bed, 23-hour CPC in a 564-bed community hospital from January 13 through May 31, 1994. In our institution, all emergency patients with acute nontraumatic chest pain of unclear origin, suggestive of myocardial ischemia but with a low probability of AMI, are transferred to the CPC for further evaluation. All patients in whom AMI is ruled out undergo individually appropriate cardiac diagnostic testing in accordance with CPC clinical guidelines. Patients with end-stage coronary artery disease transferred to the CPC for a “rule-out” protocol only did not undergo further diagnostic testing. Admitted and discharged patients were followed through chart review and telephone survey, respectively. Results: Of the 502 patients transferred to the CPC, 477 (95%) completed follow-up at 14 days. Four hundred ten (86%) were discharged home. Those discharged after diagnostic evaluation yielded negative findings had 100% survival and zero diagnosis of AMI at 5-month follow-up. Overall mortality and incidence of AMI on long-term follow-up for all patients transferred to the CPC were .4% and .2%, respectively. Sixty-seven patients (13%) were admitted from the CPC, of whom 44 (66%) had a final diagnosis of ischemic heart disease (IHD) or AMI. Twenty-four patients with IHD (55%; 6% of stress-tested group) were identified only on further stress testing. Of these patients, seven underwent percutaneous transluminal coronary angioplasty or coronary artery bypass grafting during hospitalization. All were discharged home without major morbidity. Four hundred twenty-four patients (84%) underwent stress testing. The cost of mandatory stress testing to identify one patient with IHD after AMI was ruled out was $3,125. An average cost-per-case savings of 62% was achieved for each patient transferred to the CPC who would have been hospitalized before the inception of the CPC. Conclusion: Mandatory stress testing is a safe, cost-effective, and valuable diagnostic and prognostic tool in CPC patients. [Mikhail MG, Smith FA, Gray M, Britton C, Frederiksen SM: Cost-effectiveness of mandatory stress testing in chest pain center patients. Ann Emerg Med January 1997;29:88-98.]

The role of the emergency department in the management of patients with atypical chest pain

AbstractThere is often an inconsistent approach to the management of patients with chest pain which is not due to myocardial infarction. The stratification of risk groups, utility of diagnostic tests and current practice in the USA are discussed. Recommendations for a change in our current practice are: Patients with unstable angina, acute myocardial infarction and those with a high suspicion of acute myocardial infarction should be admitted to hospital. Those patients with atypical chest pain should be considered for early exercise testing in or from the emergency department. In the absence of the facility for exercise testing in or from the emergency department, patients with atypical chest pain should be admitted to hospital.

Frequency of pulmonary embolism in patients admitted with chest pain and suspicion of acute myocardial infarction but in whom this diagnosis is ruled out.

The purpose of this study was to determine the frequency of pulmonary embolism in patients admitted with acute chest pain but without myocardial infarction (non-AMI patients). We examined 175 consecutive non-AMI patients without unstable angina pectoris within the first 48 h of admission. The patients were first examined by perfusion pulmonary scintigraphy. If the scintigraphy was abnormal, it was combined with a 81mKr ventilation scintigraphy. Perfusion scintigraphy was abnormal in 21 patients, and the subsequent combined perfusion/ventilation scintigraphy was used to identify 5 patients (2.5%) who had a high probability for pulmonary embolism, which was not clinically suspected at the time of admission. Three of these 5 patients had a decreased arterial oxygen tension upon admission, and 3 had abnormalities in their electrocardiogram. Pulmonary embolism only occurred in 2.5% of the non-AMI patients. The prognosis of untreated patients, however, it markedly worse as compared with treated patients. We, therefore, suggest that pulmonary scintigraphy be performed in non-AMI patients who have uncharacteristic electrocardiographic changes and/or a low arterial partial oxygen tension when no other abnormality has been found within 24 h of admission.