 |
|
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 increasingly used in emergency departments to diagnose acute cardiac ischemia, there have been no prospective evaluations of a chest pain diagnostic protocol with serial determinations of creatine kinase MB isoenzyme and mandatory exercise electrocardiography (ExECG).
Methods
Prospective cross-sectional study in which chest pain protocol results were compared with final (reference) diagnoses of acute cardiac ischemia (including acute myocardial infarction and unstable angina). Patients in need of hospital admission but at low probability (by a validated algorithm) for acute myocardial infarction were examined for exclusions: known coronary artery disease, cardiac complications, severe comorbidities, or inability to perform exercise testing. A 12-hour diagnostic protocol included serial measurements of creatine kinase MB, ECG, and clinical assessments followed by ExECG for those with negative initial serial testing. Reference diagnoses were established during hospitalization 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 diagnosis of acute cardiac ischemia. For this diagnosis, the protocol had a sensitivity of 90.0% (95% confidence interval, 72.3%-97.4%); specificity, 50.5% (95% confidence interval, 44.6%-56.4%); positive predictive value, 16.0%; and negative predictive value, 98.0%. Creatine kinase MB, serial ECGs, and ExECG each made a contribution to improved sensitivity and accuracy, whereas clinical reassessments were less discriminating, as indicated by protocol's receiver operating characteristic curve.
Conclusions
A chest pain diagnostic protocol achieved high sensitivity and improved specificity over the standard emergency department workup. There were no adverse advents associated with early ExECG.
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).
 CiteULike  Connotea  Del.icio.us  Digg  Reddit  Technorati  Twitter
What's this?
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
|
Cost-Effectiveness of Coronary MDCT in the Triage of Patients with Acute Chest Pain
Ladapo et al.
Am. J. Roentgenol. 2008;191:455-463.
ABSTRACT
| FULL TEXT
Identification of patients with evolving coronary syndromes by using statistical models with data from the time of presentation
Kennedy and Harrison
Heart 2006;92:183-189.
ABSTRACT
| FULL TEXT
Long-term Performance of a Simple Algorithm for Early Discharge After Ruling Out Acute Coronary Syndrome: A Prospective Multicenter Trial
Schaer et al.
Chest 2005;127:1364-1370.
ABSTRACT
| FULL TEXT
Impact of a Clinical Decision Rule on Hospital Triage of Patients With Suspected Acute Cardiac Ischemia in the Emergency Department
Reilly et al.
JAMA 2002;288:342-350.
ABSTRACT
| FULL TEXT
Diagnostic accuracy of technician supervised and reported exercise tolerance tests
Muir et al.
Heart 2002;87:381-382.
FULL TEXT
Exercise Standards for Testing and Training: A Statement for Healthcare Professionals From the American Heart Association
Fletcher et al.
Circulation 2001;104:1694-1740.
FULL TEXT
Is it possible to exclude a diagnosis of myocardial damage within six hours of admission to an emergency department? Diagnostic cohort study
Herren et al.
BMJ 2001;323:372-372.
ABSTRACT
| FULL TEXT
Screening patients with chest pain in the emergency department using electron beam tomography: a follow-up study
Georgiou et al.
J Am Coll Cardiol 2001;38:105-110.
ABSTRACT
| FULL TEXT
Randomized comparison of a strategy of predischarge coronary angiography versus exercise testing in low-risk patients in a chest pain unit: in-hospital and long-term outcomes
deFilippi et al.
J Am Coll Cardiol 2001;37:2042-2049.
ABSTRACT
| FULL TEXT
Characteristics of an Albumin Cobalt Binding Test for Assessment of Acute Coronary Syndrome Patients: A Multicenter Study
Christenson et al.
Clin. Chem. 2001;47:464-470.
ABSTRACT
| FULL TEXT
Emergency management of cardiac chest pain: a review
Herren and Mackway-Jones
Emerg. Med. J. 2001;18:6-10.
FULL TEXT
Safety and Utility of Exercise Testing in Emergency Room Chest Pain Centers : An Advisory From the Committee on Exercise, Rehabilitation, and Prevention, Council on Clinical Cardiology, American Heart Association
Stein et al.
Circulation 2000;102:1463-1467.
FULL TEXT
Chest pain evaluation units
Quin
Emerg. Med. J. 2000;17:237-240.
FULL TEXT
Impact of a Clinical Pathway on the Care and Costs of Myocardial Infarction
Kucenic et al.
ANGIOLOGY 2000;51:393-404.
ABSTRACT
Critical Pathways : A Review
Every et al.
Circulation 2000;101:461-465.
FULL TEXT
Comparison of Myocardial Perfusion Imaging and Cardiac Troponin I in Patients Admitted to the Emergency Department With Chest Pain
Kontos et al.
Circulation 1999;99:2073-2078.
ABSTRACT
| FULL TEXT
A Clinical Trial of a Chest-Pain Observation Unit for Patients with Unstable Angina
Farkouh et al.
NEJM 1998;339:1882-1888.
ABSTRACT
| FULL TEXT
Costs of an Emergency Department--Based Accelerated Diagnostic Protocol vs Hospitalization in Patients With Chest Pain: A Randomized Controlled Trial
Roberts et al.
JAMA 1997;278:1670-1676.
ABSTRACT
Chest Pain Evaluation Units: An Idea Whose Time Has Come
Hoekstra and Gibler
JAMA 1997;278:1701-1702.
ABSTRACT
|
