Skip to main content
SpringerLink
Log in

Acute chest pain — identification of patients at low risk for coronary events. The impact of symptoms, medical history and risk factors

Identifikation von Niedrig-Risiko-Patienten mit akutem Thoraxschmerz — Wertigkeit von Symptomen, Anamnese und Risikofaktoren

  • Original Article
  • Published:
Wiener Klinische Wochenschrift Aims and scope Submit manuscript

Zusammenfassung

Studienhintergrund

Die Evaluierung von Patienten mit akutem Thoraxschmerz bleibt schwierig und mit dem Risiko einer gravierenden Fehldiagnose verbunden. Es ist bekannt, dass typische Angina pectoris-Symptomatik koronare Hochrisiko-Patienten nicht sicher identifiziert. Wir untersuchten den Vorhersagewert von atypischen Charakteristika, mit Bezug auf akute Symptomatik, Anamnese und Risikofaktoren der Patienten, für den Ausschluss von akutem Myokardinfarkt oder sub-akuten koronaren Ereignissen.

Methoden

1288 konsekutive Patienten mit akutem Thoraxschmerz wurden an einer Notaufnahme untersucht. Symptome, Anamnese und Risikofaktoren wurden unter Verwendung von 7 prä-definierten Kriterien evaluiert und als typisch oder atypisch für Myokardischämie eingeteilt. Der positive Vorhersagewert (PPV) und 95% Konfidenzintervalle (95% Cl) wurden berechnet, um akuten Myokardinfarkt (AMI), und kardiale Komplikationen (MACE: kardiovaskulärer Tod, perkutane Angioplastie, Bypass Chirurgie, Myokardinfarkt) innerhalb von 6 Monaten vorherzusagen oder auszuschließen.

Ergebnisse

AMI wurde in 168 Patienten (13%) gefunden, und 6-Monate MACE (inklusive AMI) in 240 Patienten (19%). Bei Vorhandensein von ≥4 typischen Kriterien konnte AMI mit einem PPV von 0,21 (0,17 bis 0,25) vorhergesagt werden, und 6-Monate MACE mit einem PPV von 0,30 (0,25 bis 0,35). Das Vorhandensein von ≥4 atypischen Kriterien hingegen war mit einem PPV von 0,94 (0,91 bis 0,96) zum Ausschluss von AMI, und mit einem PPV von 0,93 (0,90 bis 0,96) zum Ausschluss von 6 Monate MACE verbunden. In 165 von 476 Patienten unter 40 Jahren (35%), waren AMI bzw. 6-Monate MACE bei ≥4 atypischen Kriterien mit PPVs von 0,98 (0,96 bis 1,0) auszuschließen.

Schlussfolgerung

Die Evaluierung von für eine Myokardischämie atypischen Kriterien kann bei der Identifikation von Patienten mit niedrigem Risiko hilfreich sein, während typische Kriterien nur einen eingeschränkten diagnostischen Wert besitzen.

Summary

Background

The evaluation of patients with acute chest pain remains challenging, as it implies the risk of fatal misdiagnosis. It is well recognized that typical angina does not specifically identify patients at high risk. we investigated the predictive value of characteristics atypical for myocardial ischemia for exclusion of acute or subacute coronary events, focusing on patients’ symptoms, medical history and risk factors.

Methods

We prospectively studied 1288 consecutive patients presenting with acute chest pain at a nontrauma emergency department. Patients’ symptoms, history and risk factors were evaluated using seven predefined criteria and assigned as typical or atypical for ischemic coronary chest pain. Positive predictive value (PPV) and 95% confidence intervals (95% Cl) were calculated to predict or exclude acute myocardial infarction (AMI) and major adverse cardiac events (MACE: cardiovascular death, percutaneous coronary interventions, bypass surgery, or myocardial infarction) within six months.

Results

AMI occurred in 168 patients (13%), and 6-months MACE (including AMI) overall in 240 patients (19%). Presence of four or more criteria typical for myocardial ischemia was associated with a PPV of 0.21 (0.17 to 0.25) for predicting AMI and 0.30 (0.25 to 0.35) for 6-months MACE. Presence of four or more criteria atypical for coronary ischemia was associated with a PPV of 0.94 (0.91 to 0.96) for excluding AMI and 0.93 (0.90 to 0.96) for excluding 6-months MACE. In 165 of 476 patients under 40 years of age (35%), four or more atypical criteria excluded AMI and 6-months MACE with PPVs of 0.98 (0.96 to 1.0).

Conclusion

Evaluation of criteria atypical for myocardial ischemia with acute chest pain may help to identify candidates for early discharge, whereas typical characteristics have very little diagnostic value.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

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

Instant access to the full article PDF.

Institutional subscriptions

References

  1. Karlson BW, Herlitz J, Hallgren P, Liljeqvist JA, Oden A, Hjalmarson A (1994) Emergency room prediction of mortality and severe complications in patients with suspected myocardial infarction. Eur Heart J 15: 1558–1565

    PubMed  CAS  Google Scholar 

  2. Karlson BW, Herlitz J, Strombom U, Lindqvist J, Oden A, Hjalmarson A (1997) Improvement of ED prediction of cardiac mortality among patients with symptoms suggestive of acute myocardial infarction. Am J Emerg Med 15: 1–7

    Article  PubMed  CAS  Google Scholar 

  3. Burt CW (1999) Summary statistics for acute cardiac ischemia and chest pain visits to United States EDs, 1995–1996. Am J Emerg Med 17: 552–559

    Article  PubMed  CAS  Google Scholar 

  4. Pope JH, Aufderheide TP, Ruthazer R, Woolard RH, Feldman JA, Beshansky JR, Griffiths JL, Seker HP (2000) Missed diagnosis of acute cardiac ischemia in the emergency department in the emergency department. N Engl J Med 342: 1163–1170

    Article  PubMed  CAS  Google Scholar 

  5. McCarthy BD, Beshansky JR, D’Angostino RB, Selker HP (1993) Missed diagnosis of acute myocardial infarction in the emergency department: results from a multicenter study. Ann Emerg Med 22: 579–582

    Article  PubMed  CAS  Google Scholar 

  6. Schor S, Behar S, Modan B, Barell V, Drory J, Kariv I (1976) Disposition of presumed coronary patients from an emergency room: a follow-up study. JAMA 236: 941–943

    Article  PubMed  CAS  Google Scholar 

  7. Lee TH, Rouan GW, Weisberg MC (1993) Clinical characteristics and natural history of patients with acute myocardial infarction sent home from the emergency room. Am J Cardiol 60: 219–224

    Article  Google Scholar 

  8. Bhayana V, Cohoe S, Pellar TG, Jablonsky G, Henderson AR (1994) Combination (multiple) testing for myocardial infarction using myoglobin, creatine kinase-2 (mass), and troponin T. Clin Biochem 27: 395–406

    Article  PubMed  CAS  Google Scholar 

  9. Bakker AJ, Koelemay MJ, ven Vlies B, Gorgels JP, Smits R, Tjissen JG, Haagen FD (1995) Exclusion of acute myocardial infarction. The value of measuring creatine kinase slope. Eur J Clin Chem Clin Biochem 33: 351–363

    PubMed  CAS  Google Scholar 

  10. Newby LK, Christenson RH, Ohman M, Armstrong PW, Thompson TD, Lee KL, Hamm CW, Katus PW, Ciansiolo C, Granger CB, Topol EJ, Califf RM (1998) Value of serial troponin T measures for early and late risk stratification in patients with acute coronary syndromes. Circulation 98: 1853–1859

    PubMed  CAS  Google Scholar 

  11. De Winter RJ, Bholasingh R, Niewenhuijs AB, Koster RW, Peters RJG, Sanders GT (1999) Ruling out acute myocardial infarction early with two serial creatine kinase-MBmass determinations. Eur Heart J 20: 967–972

    Article  PubMed  Google Scholar 

  12. Kontos MC, Jesse RL, Anderson FP, Schmidt KL, Ornato JP, Tatum JL (1999) Comparison of myocardial perfusion imaging and cardiac troponin 1 in patients admitted to the emergency department with chest pain. Circulation 99: 2073–2078

    PubMed  CAS  Google Scholar 

  13. Lee TH, Goldman L (2000) Evaluation of the patients with acute chest pain. N Engl J Med 342: 1187–1195

    Article  PubMed  CAS  Google Scholar 

  14. Farkouh ME, Smars PA, Reeder GS (1998) A clinical trial of a chest pain observation unit for patients with unstable angina. N Engl J Med 339: 1882–1888

    Article  PubMed  CAS  Google Scholar 

  15. Gaspoz JM, Lee TH, Weinstein MC (1994) Cost-effectiveness of a new short-stay unit to “rule out” acute myocardial infarction in low risk patients. J Am Coll Cardiol 24: 249–259

    Article  Google Scholar 

  16. Roberts RR, Zalensky RJ, Mensah EK (1997) Costs of an emergency department — based accelerated diagnostic protocol vs. hospitalization in patients with chest pain: a randomized control trial. JAMA 278: 1670–1676

    Article  PubMed  CAS  Google Scholar 

  17. Gibler WB, Runyon JP, Levy RC (1995) A rapid diagnostic and treatment center for patients with chest pain in the emergency department. Ann Emerg Med 25: 1–8

    Article  PubMed  CAS  Google Scholar 

  18. Graff L, Joseph T, Andelman R (1995) American College of Emergency Physicians information paper: chest pain units in emergency departments — a report from the shortterm observation services section. Am J Cardiol 76: 1036–1039

    Article  PubMed  CAS  Google Scholar 

  19. Gomez MA, Anderson JL, Karagounis LA, Muhlestein JB, Mooers FB (1996) An emergency department — based protocol for rapidly ruling out myocardial ischemia reduces hospital time and expense: results of a randomised study (ROMIO). J Am Coll Cardiol 28: 25–33

    Article  PubMed  CAS  Google Scholar 

  20. Nichol G, Walls R, Goldman L (1997) A critical pathway for management of patients with acute chest pain who are at low risk for myocardial ischemia: recommendations and potential impact. Ann Intern Med 127: 996–1005

    PubMed  CAS  Google Scholar 

  21. Canto JG, Fincher C, Kiefe CI, Allison JJ, Li Q, Funkhouser E, Centro RM, Selker HP, Weissman NW (2002) Atypical presentation among Medicare beneficiaries with unstable angina pectoris. Am J Cardiol 90: 248–253

    Article  PubMed  Google Scholar 

  22. Milner KA, Funk M, Arnold A, Vaccarino V (2002) Typical symptoms are predictive of acute coronary syndromes in women. Am Heart J 143: 283–288

    Article  PubMed  Google Scholar 

  23. Domanovits H, Schillinger M, Paulis M, Rauscha F, Thoennissen J, Nikfardjam M, Laggner AN (2002) Acute chest pain — a stepwise approach, the challenge of the correct clinical diagnosis. Resucitation 55: 9–14

    Article  Google Scholar 

  24. Armitage P, Berry G (1994) Statistical methods in medical research. 3rd edn. Blackwell Scientific Publications, Oxford

    Google Scholar 

  25. Schillinger M, Domanovits H, Paulis M, Nikfardjam M, Meron G, Kurkciyan I, Laggner AN (2002) Clinical signs of pulmonary congestion predict outcome in patients with acute chest pain. Wien Klin Wochenschr 114: 917–922

    PubMed  Google Scholar 

  26. Gallagher EJ (1998) Clinical utility of likelihood ratios. Ann Emerg Med 31: 391–397

    Article  PubMed  CAS  Google Scholar 

  27. Panju AA, Hemmelgarn BR, Guyatt GH, Simel DL (1998) The rational clinical examination. Is this patient having a myocardial infarction? JAMA 280: 1256–1263

    Article  PubMed  CAS  Google Scholar 

  28. Snider A, Papaleo M, Beldner S, Park C, Katechis D, Galinkin D, Fein A (2002) Is telemetry monitoring necessary in low-risk suspected acute chest pain syndromes? Chest 122: 517–523

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Angiology, Medical School, Vienna, Austria

    Martin Schillinger

  2. Department of Emergency Medicine, University of Vienna, Medical School, Vienna General Hospital, Währinger Gürtel 18-20, A-1090, Vienna, Austria

    Gottfried Sodeck, Giora Meron, Karin Janata, Anton N. Laggner & Hans Domanovits MD

  3. Department of Cardiology, University of Vienna, Medical School, Vienna, Austria

    Mariam Nikfardjam & Fritz Rauscha

Authors
  1. Martin Schillinger
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Gottfried Sodeck
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Giora Meron
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Karin Janata
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Mariam Nikfardjam
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Fritz Rauscha
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Anton N. Laggner
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Hans Domanovits MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Hans Domanovits MD.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Schillinger, M., Sodeck, G., Meron, G. et al. Acute chest pain — identification of patients at low risk for coronary events. The impact of symptoms, medical history and risk factors. Wien Klin Wochenschr 116, 83–89 (2004). https://doi.org/10.1007/BF03040701

Download citation

  • Received:

  • Accepted:

  • Issue Date:

  • DOI: https://doi.org/10.1007/BF03040701

Schlüsselwörter

Key words

Search

Navigation