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Best evidence topic report
First ECG in chest pain
Free
  1. Doug Speake,
  2. Polly Terry
  1. Department of Emergency Medicine, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK

    http://dx.doi.org/10.1136/emj.18.1.61-a

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      Report by Doug Speake, Medical Student Search checked by Polly Terry Specialist Registrar

      Clinical scenario

      A 55 year old man with cardiac sounding chest pain presents to the emergency department. The first ECG is normal. Just before you discharge him you stop to wonder what the sensitivity of the initial 12 lead ECG is in predicting acute myocardial infarction.

      Three part question

      In [patients presenting to the ED with cardiac-sounding chest pain] what is the [sensitivity] of the [initial 12 lead ECG]?

      Search strategy

      Medline 1966–09/00 using the OVID interface. [(exp myocardial infarction OR myocardial infarction.mp OR AMI.mp OR MI.mp) AND (exp electrocardiography OR electrocardiogram.mp OR ECG.mp OR EKG.mp) AND (initial.mp OR first.mp OR single.mp or premier.mp)] AND maximally sensitive diagnostic study filter LIMIT to human AND english.

      Search outcome

      Altogether 543 papers found of which 533 were irrelevant or of insufficient quality for inclusion. The remaining 10 papers are shown in table 4.

      View this table:
      Table 4

      Comments

      At presentation history, clinical findings and ECG are all that are available to aid clinicians in the diagnosis of AMI. These studies have shown that the first ECG is between 13–69% sensitive for AMI.

      Clinical bottom line

      The first ECG is not sensitive enough to rule out AMI in the emergency department.

      Report by Doug Speake, Medical Student Search checked by Polly Terry Specialist Registrar

      References

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      2. Starck M, Vacek JL. The initial electrocardiogram during admission for myocardial infarction. Arch Intern Med1987;147:843–6.
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      3. Sharkey S, Apple F, Elsperger J, et al. Early peak of creatinine kinase in acute myocardial infarction with a non-diagnostic electrocardiogram. Am Heart J1988;116:1207–11.
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      4. Fesmire F, Percy R, Wears R, et al. Initial ECG in Q wave and non-Q wave myocardial infarction. Ann Emerg Med1989;18:741–6.
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      5. Rouan G, Lee T, Cook F, et al. Clinical characteristics and outcome of acute myocardial infarction in patients with initially normal or non-specific electrocardiograms. Am J Cardiol1989;64:1087–91.
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      6. Gibler WB, Young G, Hedges J, et al. Acute myocardial infarction in chest pain patients with non-diagnostic ECGs: serial CK-MB sampling in the emergency department. Ann Emerg Med1992;21:504–12.
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      7. Young P, Green T. The role of single ECG, creatinine kinase, and CKMB in diagnosing patients with acute chest pain. Am J Emerg Med1993;11:444–9.
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      8. Zalenski R, Cooke D, Rydman R, et al. Assessing the diagnostic value of an ECG containing leads V4r, V8 and V9: the 15 lead ECG. Ann Emerg Med1993;22:786–93.
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      9. Fesmire F. Usefulness of automated serial 12-lead ECG monitoring during the initial emergency department evaluation of patients with chest pain. Ann Emerg Med1998;31:3–11.
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      10. Kudenchuk P, Maynard C, Cobb L, et al. Utility of the prehospital electrocardiogram in diagnosing acute coronary syndromes: the myocardial infarction triage and intervention (MITI) Project. J Am Coll Cardiol1998;32:17–27.
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