Skip to main content

Impact of the availability of a prior electrocardiogram on the triage of the patient with acute chest pain

Journal of General Internal Medicine volume 5, pages 381–388 (1990)Cite this article

Abstract

Study objective:To determine whether information from a prior electrocardiogram (ECG) improves diagnostic accuracy in the emergency department (ED) evaluation of patients with acute chest pain.

Design:Analysis of prospectively collected data from a cohort study.

Setting:Emergency departments of four community and three university hospitals.

Patients:5,673 patients aged ≥30 years who presented to the EDs of participating hospitals for evaluation of acute chest pain, including 772 (14%) with acute myocardial infarction (AMI).

Measurements and main results:After adjusting for clinical characteristics, no significant difference was found in the sensitivities of admission to the hospital or to the coronary care unit (CCU) between AMI patients with and without prior ECGs available for review. However, non-AMI patients with prior ECGs available for review were more likely to avoid CCU admission than were non-AMI patients without prior ECGs. This improvement in specificity was most marked in the 2,024 patients whose current ED ECGs had changes consistent with ischemia or infarction: when a prior ECG was available, non-AMI patients were more than twice as likely to be discharged (26% vs. 12%) and about 1.5 times as likely to avoid CCU admission (39% vs. 27%) (both p<0.0001). Admission rates of AMI patients with and without prior ECGs were similar.

Conclusion:When the current ECG is consistent with ischemia or infarction, the availability of a prior ECG for comparison to determine whether the ECG changes are old or new improves diagnostic accuracy and triage decisions by reducing the admission of patients without AMI or acute ischemic heart disease (increased specificity) without reducing the admission of patients with these diagnoses (unchanged sensitivity).

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

USD 39.95

Price includes VAT (USA)
Tax calculation will be finalised during checkout.

References

  1. Goldman L, Weinberg M, Weisberg MC, et al. A computer-derived protocol to aid in the diagnosis of emergency room patients with acute chest pain. N Engl J Med. 1982;307:588–96.

    PubMed  CAS  Article  Google Scholar 

  2. Goldman L, Cook EF, Brand DA, et al. A computer protocol to predict myocardial infarction in emergency department patients with chest pain. N Engl J Med. 1988;318:797–802.

    PubMed  CAS  Article  Google Scholar 

  3. Pozen MW, D’Agostino RB, Selker HP, Sytkowski PA, Hood WB. A predictive instrument to improve coronary-care-unit admission practices in acute ischemic heart disease. A prospective multicenter clinical trial. N Engl J Med. 1984;310:1273–8.

    PubMed  CAS  Article  Google Scholar 

  4. Rubenstein LZ, Greenfield S. The baseline ECG in the evaluation of acute cardiac complaints. JAMA. 1980;244:2536–9.

    PubMed  Article  CAS  Google Scholar 

  5. Hoffman JR, Igarashi E. Influence of electrocardiographic findings on admission decisions in patients with acute chest pain. Am J Med. 1985;79:699–707.

    PubMed  Article  CAS  Google Scholar 

  6. Lee TH, Cook EF, Weisberg MC, Sargent RK, Wilson C, Goldman L. Acute chest pain in the emergency room. Identification and examination of low-risk patients. Arch Intern Med. 1985;145:65–9.

    PubMed  Article  CAS  Google Scholar 

  7. Lee TH, Rouan GW, Weisberg MC, et al. Sensitivity of routine clinical criteria for diagnosing myocardial infarction within 24 hours of hospitalization. Ann Intern Med. 1987;106:181–6.

    PubMed  CAS  Google Scholar 

  8. Lee TH, Weisberg M, Cook EF, Daley K, Brand DA, Goldman L. Evaluation of creatine kinase and creatine kinase-MB for diagnosing myocardial infarction. Clinical impact in the emergency room. Arch Intern Med. 1987;147:115–21.

    PubMed  Article  CAS  Google Scholar 

  9. Lee TH, Cook EF, Weisberg MC, Brand DA, Rouan GW, Goldman L. Candidates for thrombolysis among emergency department patients with acute chest pain: the Multicenter Chest Pain Study experience. Ann Intern Med. 1989;110:957–62.

    PubMed  CAS  Google Scholar 

  10. Solomon CG, Lee TH, Cook EF, et al. Comparison of clinical presentation of acute myocardial infarction in patients older than 65 years of age to younger patients: the Multicenter Chest Pain Study experience. Am J Cardiol. 1989;63:772–6.

    PubMed  Article  CAS  Google Scholar 

  11. Beamer AD, Lee TH, Cook EF, et al. Diagnostic implications of the circadian variation of the onset of chest pain. Am J Cardiol. 1987;60:998–1002.

    PubMed  Article  CAS  Google Scholar 

  12. Cunningham MA, Lee TH, Cook EF, et al. The effect of gender on the probability of myocardial infarction among emergency department patients with acute chest pain. J Gen Intern Med. 1989;4:392–8.

    PubMed  CAS  Google Scholar 

  13. White LD, Lee TH, Cook EF, et al, and the Chest Pain Study Group. Comparison of the natural history of new onset and exacerbated chronic ischemic heart disease. J Am Coll Cardiol (in press).

  14. Miettinen OS, Cook EF. Confounding: essence and detection. Am J Epidemiol. 1981;114:593–603.

    PubMed  CAS  Google Scholar 

  15. Miettinen OS. Stratification by a multivariate confounder score. Am J Epidemiol. 1976;104:609–20.

    PubMed  CAS  Google Scholar 

  16. Rosenbaum PR, Rubin DB. The central role of the propensity score in observational studies for causal effect. Biometrika. 1983;70:41–55.

    Article  Google Scholar 

  17. Mantel N, Haenszel W. Statistical aspects of the analysis of data from retrospective studies of disease. J Nat Cancer Inst. 1959;22:719–48.

    PubMed  CAS  Google Scholar 

  18. Kleinbaum DG, Kupper LL, Morgenstern H. Epidemiologic research. Principles and quantitative methods. New York: Van Nostrand Reinhold, 1982;345.

    Google Scholar 

  19. Freiman JA, Chalmers TC, Smith H, Kuebler RR. The importance of beta, the type II error and sample size in the design and interpretation of the randomized control trial. N Engl J Med. 1978;299:690–4.

    PubMed  CAS  Article  Google Scholar 

  20. Feinstein AR. An additional basic science for clinical medicine: II. The limitations of randomized trials. Ann Intern Med. 1983;99:544–50.

    PubMed  CAS  Google Scholar 

  21. Califf RM, Pryor DB, Greenfield JC. Beyond randomized clinical trials: applying clinical experience in the treatment of patients with coronary artery disease. Circulation. 1986;74:1191–4.

    PubMed  CAS  Google Scholar 

  22. Resnekov L, Fox S, Selzer A, et al. The quest for optimal electrocardiography: task force IV: use of electrocardiograms in practice. Am J Cardiol. 1978;41:170–5.

    PubMed  Article  CAS  Google Scholar 

  23. Goldberger AL, O’Konski M. Utility of the routine electrocardiogram before surgery and on general hospital admission. Ann Intern Med. 1986;105:552–7.

    PubMed  CAS  Google Scholar 

  24. Moorman JR, Hlatky MA, Eddy DM, Wagner GS. The yield of the routine admission electrocardiogram: a study in a general medical service. Ann Intern Med. 1985;103:590–5.

    PubMed  CAS  Google Scholar 

  25. Rabkin SW, Horne JM. Preoperative electrocardiography: its cost-effectiveness in detecting abnormalities when a previous tracing exists. Can Med Assoc J. 1979;121:301–6.

    PubMed  CAS  Google Scholar 

  26. Ferrer MI. The value of obligatory preoperative electrocardiograms: a survey of 1260 patients. J Am Med Wom Assoc. 1978;33:459–64.

    PubMed  CAS  Google Scholar 

  27. Diagnostic and therapeutic technology assessment: mandatory ECG before elective surgery. JAMA. 1983;250:540.

    Google Scholar 

  28. Howland WS, Schmeitzer O, LaDue JS. Evaluation of routine post-operative electrocardiography. N Y State J Med. 1962;62:1941–5.

    PubMed  CAS  Google Scholar 

  29. Tommaso CL, Salzeider K, Arif M, et al. Serial myoglobin vs CPK analysis as an indicator of uncomplicated myocardial infarction size and its use in assessing early infarct extension. Am Heart J. 1980;99:149–54.

    PubMed  Article  CAS  Google Scholar 

  30. Cairns JA, Missirlis E, Walker WH. Usefulness of serial determinations of myoglobin and creatine kinase in serum compared for assessment of acute myocardial infarction. Clin Chem. 1983;29:469–73.

    PubMed  CAS  Google Scholar 

  31. Jaffe AS, Serota H, Grace A, Sobel BE. Diagnostic changes in plasma creatine kinase isoforms early after the onset of acute myocardial infarction. Circulation. 1986;74:105–9.

    PubMed  CAS  Google Scholar 

  32. Horwitz RS, Morganroth J. Immediate detection of early high-risk patients with acute myocardial infarction using two-dimensional echocardiographic evaluation of left ventricular regional wall motion abnormalities. Am Heart J. 1982;103:814–22.

    Article  Google Scholar 

  33. Wackers FJT, Lie KI, Leim KL, et al. Potential value of thallium-201 scintigraphy as a means of selecting patients for the coronary care unit. Br Heart J. 1979;41:111–7.

    PubMed  CAS  Google Scholar 

  34. Lee TH, Goldman L. The coronary care unit turns 25: historical trends and future directions. Ann Intern Med. 1988;108:887–94.

    PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Division of Clinical Epidemiology, Consolidated Department of Medicine, Brigham and Women’s and Beth Israel Hospitals, 75 Francis Street, 02115, Boston, MA

    Lee Goldman MD, MPH

Authors
  1. Thomas H. Lee MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. E. Francis Cook ScD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Monica C. Weisberg
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Gregory W. Rouan MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Donald A. Brand PhD
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Lee Goldman MD, MPH
    View author publications

    You can also search for this author in PubMed Google Scholar

Additional information

Received from Brigham and Women’s Hospital, Harvard Medical School, and Harvard School of Public Health, Boston, Massachusetts; Yale-New Haven Hospital and Yale University School of Medicine, New Haven, Connecticut; University of Cincinnati Hospital and University of Cincinnati, Cincinnati, Ohio; Danbury Hospital, Danbury, Connecticut; Milford Hospital, Milford, Connecticut; St. Mary’s Hospital, Waterbury, Connecticut; and William Beaumont Hospital, Royal Oak, Michigan.

Supported in part by grants from the John A. Hartford Foundation, New York, New York (83102-2H) and from the Robert Wood Johnson Foundation, Princeton, New Jersey (12543) Dr. Lee is the recipient of a Public Health Service Clinical Investigator Award (HL01594-05) from the National Heart, Lung, and Blood Institute. Dr. Rouan was a Teaching and Research Scholar of the American College of Physicians and was supported in part by a grant to the Training Program in Clinical Effectiveness from the W. K. Kellogg Foundation.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Lee, T.H., Cook, E.F., Weisberg, M.C. et al. Impact of the availability of a prior electrocardiogram on the triage of the patient with acute chest pain. J Gen Intern Med 5, 381–388 (1990). https://doi.org/10.1007/BF02599421

Download citation

  • Issue Date:

  • DOI: https://doi.org/10.1007/BF02599421

Key words

  • chest pain
  • myocardial infarction
  • electrocardiography
  • diagnosis