This Article  • References  • Full text PDF  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Citing articles on HighWire  • Citing articles on Web of Science (244)  • Contact me when this article is cited  Related Content  • Similar articles in this journal  Social Bookmarking   What's this?

Identification and Examination of Low-Risk Patients

Thomas H. Lee, MD; E. Francis Cook, ScD; Monica Weisberg, RN; R. Kent Sargent, MD; Clyde Wilson, MD; Lee Goldman, MD

Arch Intern Med. 1985;145(1):65-69.

Abstract
• Clinical and laboratory data from 596 patients who came to an emergency room complaining of chest pain indicated that no single variable could identify low-risk patients as well as a normal ECG. A combination of three variables—sharp or stabbing pain, no history of angina or myocardial infarction, and pain with pleuritic or positional components or pain that was reproduced by palpation of the chest wall—defined a very-low-risk group in which ECGs did not add accuracy to the evaluation and were potentially misleading; however, only 48 patients (8%) fell into this category. Standard cardiac enzyme levels were of almost no use as an emergency room indicator of myocardial infarction. These findings emphasize the difficulty of identifying patients at low risk for myocardial infarction or unstable angina in the emergency room without consideration of many factors from the history, the physical examination, and the ECG.

(Arch Intern Med 1985;145:65-69)

Author Affiliations
From the Cardiovascular Division (Drs Lee and Goldman) and the Division of General Medicine (Drs Lee, Cook, Sargent, Wilson, and Goldman and Ms Weisberg), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston. Dr Goldman is a Henry J. Kaiser Family Foundation Faculty Scholar in General Internal Medicine.

Footnotes
Accepted for publication April 25, 1984.

Reprint requests to Department of Medicine, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115 (Dr Goldman).

CiteULike    Connotea    Del.icio.us    Digg    Reddit    Technorati    Twitter     What's this?

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

CHAPTER 1 The Cardiovascular History and Physical Examination
Hall and Simpson
ESC Textbook of Cardiovascular Medicine 2009;2:med-9780199566990-chapter-med-9780199566990-chapter.
ABSTRACT | FULL TEXT  

Ischemia Modified Albumin, a Marker of Acute Ischemic Events: A Pilot Study
Talwalkar et al.
Annals of Clinical & Laboratory Science 2008;38:132-137.
ABSTRACT | FULL TEXT  

ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction) Developed in Collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine
Anderson et al.
J Am Coll Cardiol 2007;50:e1-e157.
FULL TEXT  

ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction) Developed in Collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine
Anderson et al.
J Am Coll Cardiol 2007;50:652-726.
FULL TEXT  

Myocardial Ischemic Memory Imaging With Molecular Echocardiography
Villanueva et al.
Circulation 2007;115:345-352.
ABSTRACT | FULL TEXT  

ECG-Gated 64-MDCT Angiography in the Differential Diagnosis of Acute Chest Pain
Johnson et al.
Am. J. Roentgenol. 2007;188:76-82.
ABSTRACT | FULL TEXT  

Coronary CT Angiography
Hoffmann et al.
JNM 2006;47:797-806.
ABSTRACT | FULL TEXT  

Part 5: Acute Coronary Syndromes
Circulation 2005;112:III-55-III-72.
FULL TEXT  

Regional left ventricular perfusion and function in patients presenting to the emergency department with chest pain and no ST-segment elevation
Rinkevich et al.
Eur Heart J 2005;26:1606-1611.
ABSTRACT | FULL TEXT  

Risk stratification of patients with acute chest pain and normal troponin concentrations
Sanchis et al.
Heart 2005;91:1013-1018.
ABSTRACT | FULL TEXT  

Stress Imaging in Chest Pain Units: Is Less More?
Amsterdam and Lewis
Mayo Clin Proc. 2005;80:317-319.
 

Triage of Patients with Acute Chest Pain and Possible Cardiac Ischemia: The Elusive Search for Diagnostic Perfection
Goldman and Kirtane
ANN INTERN MED 2003;139:987-995.
ABSTRACT | FULL TEXT  

Clinical predictors of acute coronary syndromes in patients with undifferentiated chest pain
Goodacre et al.
QJM 2003;96:893-898.
ABSTRACT | FULL TEXT  

Management of acute coronary syndromes in patients presenting without persistent ST-segment elevation
Bertrand et al.
Eur Heart J 2002;23:1809-1840.
FULL TEXT  

Task force on the management of chest pain
Erhardt et al.
Eur Heart J 2002;23:1153-1176.
FULL TEXT  

Immediate exercise testing to evaluate low-risk patients presenting to the emergency department with chest pain
Amsterdam et al.
J Am Coll Cardiol 2002;40:251-256.
ABSTRACT | FULL TEXT  

Prognostic Value of a Normal or Nonspecific Initial Electrocardiogram in Acute Myocardial Infarction
Welch et al.
JAMA 2001;286:1977-1984.
ABSTRACT | FULL TEXT  

Defining the role of chest pain units
Lewis and Amsterdam
J Am Coll Cardiol 2001;37:2050-2052.
FULL TEXT  

Safety and Feasibility of Two-Dimensional Echocardiography and Myocardial Perfusion Imaging in Patients with Chest Pain
Paventi et al.
ANGIOLOGY 2001;52:305-309.
ABSTRACT  

Safe discharge from the cardiac emergency room with a rapid rule-out myocardial infarction protocol using serial CK-MBmass
Bholasingh et al.
Heart 2001;85:143-148.
ABSTRACT | FULL TEXT  

Validated risk stratification model accurately predicts low risk in patients with unstable angina
Calvin et al.
J Am Coll Cardiol 2000;36:1803-1808.
ABSTRACT | FULL TEXT  

Ability of troponin I to predict cardiac events in patients admitted from the emergency department
Kontos et al.
J Am Coll Cardiol 2000;36:1818-1823.
ABSTRACT | FULL TEXT  

ACC/AHA guidelines for the management of patients with unstable angina and non-st-segment elevation myocardial infarction: A report of the american college of cardiology/ american heart association task force on practice guidelines (committee on the management of patients with unstable angina)
Braunwald et al.
J Am Coll Cardiol 2000;36:970-1062.
FULL TEXT  

Management of acute coronary syndromes: acute coronary syndromes without persistent ST segment elevation. Recommendations of the Task Force of the European Society of Cardiology: Recommendations of the Task Force of the European Society of Cardiology
Bertrand et al.
Eur Heart J 2000;21:1406-1432.
 

The TIMI Risk Score for Unstable Angina/Non-ST Elevation MI: A Method for Prognostication and Therapeutic Decision Making
Antman et al.
JAMA 2000;284:835-842.
ABSTRACT | FULL TEXT  

Cardiac troponin T in chest pain unit patients without ischemic electrocardiographic changes: angiographic correlates and long-term clinical outcomes
deFilippi et al.
J Am Coll Cardiol 2000;35:1827-1834.
ABSTRACT | FULL TEXT  

Safety and prognostic value of early dobutamine-atropine stress echocardiography in patients with spontaneous chest pain and a non-diagnostic electrocardiogram
Geleijnse et al.
Eur Heart J 2000;21:397-406.
ABSTRACT  

Risk stratification of emergency department patients with acute coronary syndromes using P-Selectin
Hollander et al.
J Am Coll Cardiol 1999;34:95-105.
ABSTRACT | FULL TEXT  

Immediate exercise testing of low risk patients with known coronary artery disease presenting to the emergency department with chest pain
Lewis et al.
J Am Coll Cardiol 1999;33:1843-1847.
ABSTRACT | FULL TEXT  

Prognostic Value of the Admission Electrocardiogram in Acute Coronary Syndromes
Savonitto et al.
JAMA 1999;281:707-713.
ABSTRACT | FULL TEXT  

Myocardial contrast echocardiography in acute myocardial infarction: time to test for routine clinical use?
KAUL
Heart 1999;81:2-5.
FULL TEXT  

Is This Patient Having a Myocardial Infarction?
Panju et al.
JAMA 1998;280:1256-1263.
ABSTRACT | FULL TEXT  

Influence of insurance type on the use of procedures, medications and hospital outcome in patients with unstable angina: results from the GUARANTEE registry
Every et al.
J Am Coll Cardiol 1998;32:387-392.
ABSTRACT | FULL TEXT  

Biochemical markers of the acute coronary syndromes
Christenson and Azzazy
Clin. Chem. 1998;44:1855-1864.
ABSTRACT | FULL TEXT  

Cardiac troponin I as a predictor of major cardiac events in emergency department patients with acute chest pain
Polanczyk et al.
J Am Coll Cardiol 1998;32:8-14.
ABSTRACT | FULL TEXT  

Assessment of Cocaine Use in Patients With Chest Pain Syndromes
Hollander et al.
Arch Intern Med 1998;158:62-66.
ABSTRACT | FULL TEXT  

An Evaluation of a Chest Pain Diagnostic Protocol to Exclude Acute Cardiac Ischemia in the Emergency Department
Zalenski et al.
Arch Intern Med 1997;157:1085-1091.
ABSTRACT  

Cardiac Troponin T Levels for Risk Stratification in Acute Myocardial Ischemia
Ohman et al.
NEJM 1996;335:1333-1342.
ABSTRACT | FULL TEXT  

Cost-effectiveness of a Coronary Care Unit Versus an Intermediate Care Unit for Emergency Department Patients With Chest Pain
Tosteson et al.
Circulation 1996;94:143-150.
ABSTRACT | FULL TEXT  

Electrocardiographic Diagnosis of Acute Myocardial Infarction in the Presence of Left Bundle-Branch Block
Ackermann et al.
NEJM 1996;335:131-133.
FULL TEXT  

Evaluation of the Patient With 'Rule Out Myocardial Infarction'
Lewis and Amsterdam
Arch Intern Med 1996;156:41-45.
ABSTRACT  

Cocaine-Associated Myocardial Infarction: Mortality and Complications
Hollander et al.
Arch Intern Med 1995;155:1081-1086.
ABSTRACT  

A Neural Network Trained to Identify the Presence of Myocardial Infarction Bases Some Decisions on Clinical Associations That Differ from Accepted Clinical Teaching
Baxt
Med Decis Making 1994;14:217-222.
ABSTRACT  

Early "Step-Down" Transfer of Low-Risk Patients with Chest Pain: A Controlled Interventional Trial
Weingarten et al.
ANN INTERN MED 1990;113:283-289.
ABSTRACT  

Triage Considerations in Medical Intensive Care
Franklin et al.
Arch Intern Med 1990;150:1455-1459.
ABSTRACT  

The Coronary Care Unit Turns 25: Historical Trends and Future Directions
LEE and GOLDMAN
ANN INTERN MED 1988;108:887-894.
ABSTRACT  

Use of Sequential Cardiac Enzyme Analysis in Stratification of Risk for Myocardial Infarction in Patients With Unstable Angina
Quale et al.
Arch Intern Med 1988;148:1277-1279.
ABSTRACT  

Prediction Rules for Patients With Suspected Myocardial Infarction: Applying Guidelines in Community Hospitals
Young et al.
Arch Intern Med 1987;147:1219-1222.
ABSTRACT  

Serum Enzyme Assays in Acute Myocardial Infarction
VISKIN et al.
ANN INTERN MED 1987;106:473-474.
ABSTRACT  

Sensitivity of Routine Clinical Criteria for Diagnosing Myocardial Infarction Within 24 Hours of Hospitalization
LEE et al.
ANN INTERN MED 1987;106:181-186.
ABSTRACT  

A Review of Atypical Clinical Manifestations of Acute Myocardial Infarction
Neill
J Intensive Care Med 1987;2:25-32.
ABSTRACT  

Evaluation of Creatine Kinase and Creatine Kinase--MB for Diagnosing Myocardial Infarction: Clinical Impact in the Emergency Room
Lee et al.
Arch Intern Med 1987;147:115-121.
ABSTRACT  

Serum Enzyme Assays in the Diagnosis of Acute Myocardial InfarctionRecommendations Based on a Quantitative Analysis
LEE and GOLDMAN
ANN INTERN MED 1986;105:221-233.
ABSTRACT  

Cost-effective Cardiology: The New Challenge
Bogden and Schatz
JAMA 1985;253:400-400.
ABSTRACT  

Risk Stratification: A Cost-effective Approach to the Treatment of Patients With Chest Pain
Plotnick and Fisher
Arch Intern Med 1985;145:41-42.
ABSTRACT