An Evaluation of a Chest Pain Diagnostic Protocol to Exclude Acute Cardiac Ischemia in the Emergency Department

doi:10.1001/archinte.1997.00440310049005

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Vol. 157 No. 10, 26 MAY 1997

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An Evaluation of a Chest Pain Diagnostic Protocol to Exclude Acute Cardiac Ischemia in the Emergency Department

Robert J. Zalenski, MA, MD; Madeline McCarren, PhD; Rebecca Roberts, MD; Robert J. Rydman, PhD; Borko Jovanovic, PhD; Krishna Das, MD; Jose Mendez, MD; Maan El-Khadra, MD; Lesa Fraker, MD, PhD; Michael McDermott, MD

Arch Intern Med. 1997;157(10):1085-1091.

Abstract

Background
Although accelerated diagnostic protocols are being increasinglyused in emergency departments to diagnose acute cardiac ischemia,there have been no prospective evaluations of a chest pain diagnosticprotocol with serial determinations of creatine kinase MB isoenzymeand mandatory exercise electrocardiography (ExECG).

Methods
Prospective cross-sectional study in which chest pain protocolresults were compared with final (reference) diagnoses of acutecardiac ischemia (including acute myocardial infarction andunstable angina). Patients in need of hospital admission butat low probability (by a validated algorithm) for acute myocardialinfarction were examined for exclusions: known coronary arterydisease, cardiac complications, severe comorbidities, or inabilityto perform exercise testing. A 12-hour diagnostic protocol includedserial measurements of creatine kinase MB, ECG, and clinicalassessments followed by ExECG for those with negative initialserial testing. Reference diagnoses were established duringhospitalization and diagnostic accuracy was assessed.

Results
The study group of 317 patients was 54% male and 65% black,and had a mean age of 46.6 years; 9.5% had a final diagnosisof acute cardiac ischemia. For this diagnosis, the protocolhad a sensitivity of 90.0% (95% confidence interval, 72.3%-97.4%);specificity, 50.5% (95% confidence interval, 44.6%-56.4%); positivepredictive value, 16.0%; and negative predictive value, 98.0%.Creatine kinase MB, serial ECGs, and ExECG each made a contributionto improved sensitivity and accuracy, whereas clinical reassessmentswere less discriminating, as indicated by protocol's receiveroperating characteristic curve.

Conclusions
A chest pain diagnostic protocol achieved high sensitivity andimproved specificity over the standard emergency departmentworkup. There were no adverse advents associated with earlyExECG.

Arch Intern Med. 1997;157:1085-1091

Author Affiliations

From the Department of Emergency Medicine (Drs Zalenski, Roberts, Rydman, and McDermott), Department of Medicine (Dr Das), and Division of Cardiology (Drs Mendez and El-Khadra), Cook County Hospital, Chicago, Ill; and Center for Health Services Research, School of Public Health, University of Illinois at Chicago (Drs Zalenski, McCarren, Rydman, and Jovanovic); Departments of Emergency Medicine and Medicine, Wayne State University School of Medicine, Detroit, Mich (Dr Zalenski); and Department of Emergency Medicine, College of Medicine, University of Illinois at Chicago (Dr Fraker).

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