Feasability of a Rapid Diagnostic Protocol for an Emergency Department Chest Pain Unit☆,☆☆,★,★★
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INTRODUCTION
Suspected coronary heart disease (CHD), because of high disease prevalence and mortality, requires a very sensitive emergency department evaluation. To minimize inappropriate discharges of patients with acute cardiac ischemia, emergency physicians initiate inhospital evaluation for all patients who meet a low threshold of disease likelihood.1, 2, 3 High sensitivity is secured at the expense of specificity and considerable public resource consumption ($3 billion) in the hospitalization of 3
MATERIALS AND METHODS
This observational study examined a representative subset of all patients with chest pain suggestive of acute cardiac ischemia who needed hospital admission for further evaluation. Each patient slated for hospital admission was assigned a high or low probability of AMI, based on a valid, standardized algorithm developed by Goldman et al.1 The target group, patients with low probability of AMI needing hospital admission, were further examined for inclusion and exclusion criteria.
This study was
RESULTS
Of the 500 ED patients admitted to rule out ischemic heart disease who were examined for eligibility for the short-stay protocol, 446 (89.2%) had sufficient data points to determine protocol eligibility. Of these, 238 (53.3%; 95% CI, 48.7% to 57.9%) were found to have low probability of AMI, and 46.7% were found to have high probability. Of the low-probability patients, 40% were so classified because they had no new ECG findings and their pain had lasted longer than 48 hours; 29% had no new ECG
DISCUSSION
Although most patients admitted for chest pain had a low probability of AMI, the short-stay protocol, as configured for this study, applied to only 27% of them, representing 14% of the total. Although this proportion was lower than anticipated, it was nonetheless large enough to provide an important part of a strategy to decrease the burden of hospital admissions.
The short-stay CPOU protocol is appropriate only for patients with low probability of AMI.9 Therefore, the upper limit of the
References (18)
- et al.
Outcome of patients who were admitted to a new short-stay unit to “rule-out” myocardial infarction
Am J Cardiol
(1991) - et al.
A rapid diagnostic and treatment center for patients with chest pain in the emergency department
Ann Emerg Med
(1995) - et al.
Utility and safety of immediate exercise testing of low-risk patients admitted to the hospital for suspected acute myocardial infarction
Am J Cardiol
(1994) - et al.
Noninvasive predictors of sudden cardiac death in men with coronary heart disease: predictive value of maximal stress testing
Am J Cardiol
(1977) - et al.
A computer protocol to predict myocardial infarction in emergency department patients with chest pain
N Engl J Med
(1988) - et al.
Use of the initial electrocardiogram to predict in-hospital complications of acute myocardial infarction
N Engl J Med
(1985) - et al.
A tool for judging coronary care unit admission appropriateness, valid for both real-time and retrospective use: A time-insensitive predictive instrument (TIPI) for acute cardiac ischemia. A multicenter study
Med Care
(1991) - et al.
Earlier diagnosis and treatment of acute myocardial infarction necessitates the need for a “new diagnostic mindset.”
Circulation
(1994) Growth in chest pain emergency departments throughout the United States: A cardiologist’s spin on solving the heart attack problem
Coronary Artery Disease
(1995)
Cited by (63)
Endothelial function predicts 1-year adverse clinical outcome in patients hospitalized in the emergency department chest pain unit
2017, International Journal of CardiologyImaging Patients with Chest Pain in the Emergency Department
2010, Clinical Nuclear Cardiology: State of the Art and Future DirectionsImaging patients with chest pain in the emergency department
2010, Clinical Nuclear CardiologyYield of Early Rest and Stress Myocardial Perfusion Single-Photon Emission Computed Tomography and Electrocardiographic Exercise Test in Patients With Atypical Chest Pain, Nondiagnostic Electrocardiogram, and Negative Biochemical Markers in the Emergency Department
2007, American Journal of CardiologyThe Impact of Alcohol, Tobacco, and Other Drug Use and Abuse in the Emergency Department
2006, Emergency Medicine Clinics of North AmericaCitation Excerpt :An estimated 5.6 million visits are made to EDs in the United States for chest pain at a cost of more than $5 billion each year [159]. Most of these patients are at low risk for myocardial infarction [160]. Between 85% and 90% of patients who present to the observation unit with chest pain are ruled out for myocardial infarction and other serious cardiac events [161–163].
Acute rest myocardial perfusion imaging for chest pain
2004, Journal of Nuclear Cardiology
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From the Department of Emergency Medicine*, and the Department of Medicine‡, Cook County Hospital; and the Center for Health Services Research§ the Division of Health Policy and Administration∥, and the Division of Epidemiology and Biometry¶, School of Public Health, University of Illinois, Chicago, Illinois.
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Supported in part by the Agency for Health Care Policy and Research, grant number R01-HS-07103.
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Address for reprints: Robert J Zalenski, MD, Department of Emergency Medicine, Wayne State University, 4201 St Antoine, Detroit, Michigan 48201, E-mail [email protected]
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Reprint no. 47/1/78479