Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting With Suspected Acute Myocardial Infarction or Unstable Angina

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Abstract

This clinical policy focuses on critical issues in the evaluation and management of patients with acute myocardial infarction or unstable angina. A MEDLINE search for articles published between January 1993 and December 1998 was performed using combinations of the key words chest pain, acute myocardial infarction, unstable angina, thrombolytics, primary angioplasty, 12-lead ECG, ST-segment monitoring, cardiac serum markers, and chest pain centers. Subcommittee members and expert peer reviewers also supplied articles with direct bearing on the policy. This policy focuses on 5 areas of current interest and/or controversy: (1) ECG eligibility criteria for fibrinolytic therapy, (2) role of primary angioplasty in patients with acute myocardial infarction, (3) use of serum markers to diagnose acute myocardial infarction, (4) serial 12-lead ECGs during the initial evaluation, and (5) chest pain evaluation units. Recommendations for patient management are provided for each of these 5 topics based on strength of evidence (Standards, Guidelines, Options). Standards represent patient management principles that reflect a high degree of clinical certainty; Guidelines represent patient management principles that reflect moderate clinical certainty; and Options represent other patient management strategies based on preliminary, inconclusive, or conflicting evidence, or based on panel consensus. This guideline is intended for physicians working in hospital-based emergency departments or chest pain evaluation units.

[American College of Emergency Physicians. Clinical policy: critical issues in the evaluation and management of adult patients presenting with suspected acute myocardial infarction or unstable angina. Ann Emerg Med. May 2000;35:521-544.]

Introduction

Chest pain is one of the most common and complex symptoms for which patients seek emergency department care. The diagnoses for patients with chest pain range from minor disease processes such as chest wall strain or indigestion to life-threatening conditions such as acute myocardial infarction (AMI) or aortic dissection. Not only does missing a life-threatening condition result in potential serious morbidity and mortality to the patient, but this represents a frequent cause of malpractice suits against emergency physicians and the most dollars awarded.1, 2 For these reasons, the American College of Emergency Physicians (ACEP) chose chest pain as the topic of its first clinical policy, which was published in 19903 and revised in 1995.4 The format of the initial and revised chest pain clinical policies focused on the evaluation of a patient presenting with a chief complaint of chest pain as opposed to specific disease processes. It was a broad-based attempt to focus on key history, physical, and diagnostic findings to drive the diagnosis of potentially serious medical conditions with emphasis on AMI, aortic dissection, pericarditis, myocarditis, pneumonia, pulmonary embolus, pneumothorax, and pulmonary edema. Because of the all-inclusive nature of the previous policies, the format did not allow specific emphasis on critical issues in the evaluation of selected subsets of chest pain patients.

Over the past decade there has been an explosion of published research and development of new diagnostic modalities and therapies relating to disorders causing chest pain. These newer diagnostic and therapeutic modalities are being developed at a pace that far exceeds the ability of one physician to keep track. This current policy is a scheduled revision of the previous chest pain clinical policy. However, the Clinical Policies Committee believed that the format of the previous complaint-based clinical policy had gone as far as possible in directing the appropriate evaluation and treatment of patients presenting with chest pain. The committee was satisfied that the original policy had met the original goals of ACEP. This has been exemplified by the use of clinical policies to direct physician education and research, its utilization by quality improvement personnel in individual hospitals, its use in medical malpractice cases for establishing a reasonable standard of care, and its utilization by private companies in creating templates for physician history and physicals. A decision was made to develop a revised policy that focuses on critical issues in the evaluation and management of patients with AMI or unstable angina. It is hoped that departure from the previous format will not only improve patient care, but also direct critical areas of future research.

Section snippets

Methodology

This clinical policy was created after careful review and critical analysis of the peer-reviewed literature. A MEDLINE search for articles published between January 1993 and December 1998 was performed using combinations of the key words chest pain, AMI, unstable angina, and thrombolytics. Abstracts were reviewed by subcommittee members, who then selected the following topics on which to focus this policy: (1) ECG eligibility criteria for fibrinolytic therapy, (2) role of primary angioplasty in

Scope of Application

This guideline is intended for physicians working in hospital-based emergency departments or chest pain center evaluation units.

Specific Clinical Policies

ECG Eligibility Criteria for Emergent Fibrinolytic Therapy, 525

The Role of Primary Angioplasty in Patients Presenting with Acute Myocardial Infarction, 532

Serum Marker Analysis in Acute Myocardial Infarction, 534

Serial 12-Lead ECGS in the Emergency Department, 539

Chest Pain Evaluation Units, 541

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      A review of potentially relevant abstracts was performed for possible inclusion in this policy. References from the 2000 ACEP clinical policy and the 2004 American College of Cardiology/American Heart Association (ACC/AHA) AMI guidelines were also reviewed for inclusion in this policy.1,2 Finally, a detailed review of the FTT Collaborative Group and the 9 references included in this report was performed.14

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    Approved by the ACEP Board of Directors, January 17, 2000.

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