Medical decision making in patients with chest pain

Article Abstract:

In the May 2, 1991 issue of The New England Journal of Medicine, a group of physicians present the results of a trial of a protocol they devised for determining which patients with a questionable diagnosis of heart attack may be watched for 12 hours and then discharged from a coronary care or intermediate care unit. Currently, patients not considered at high risk are monitored in a coronary care unit for at least 24 hours. The study found that the patients who were observed for 12 hours suffered a low rate of cardiac complications. While the results are encouraging, it is important to point out that while the patients could, in principle, have been discharged after 12 hours, in practice they were not; the decision to discharge the patients was made by the patients' own physicians rather than by the clinicians who conducted the trial. This introduces a serious question into the interpretation of the results. There is no way to determine if the patients might have benefitted from the additional time spent in the hospital. This issue would become critical if institutions were to actually adopt the procedure of case evaluation described in the article. Nevertheless, experience has shown that, when the coronary care unit is full or if there is a staff shortage, doctors are quite efficient at triage (determining who needs to be treated immediately and who will probably recover without such treatment). The method of triage that is presented in the article should probably only be regarded as a starting point for developing a set of criteria. The model presented did not take into account patients with unstable angina and other cardiac conditions. It must be remembered that the patients grouped together as low-risk in the published study are, in fact, a heterogeneous group. Some of the patients within this group may benefit from prolonged therapy, independent of their risk of heart attack, per se. The development of triage models does not replace the necessity for thoughtful clinical assessment of patients. (Consumer Summary produced by Reliance Medical Information, Inc.)

Methods, Evaluation, Medical protocols, Triage (Medicine)

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Evaluation of chest pain in the emergency department

Article Abstract:

Evaluation of chest pain in the emergency department can be difficult and confusing. The electrocardiogram (ECG) is a key diagnostic tool in determining which patients require more extensive inpatient assessment. In the absence of ECG evidence, blood assays indicative of heart attack or cardiac compromise can be illuminating. Troponins in the blood can signify death of heart tissue and are associated with high cardiac risk. The best clinical approach to cardiac symptoms in patients without measurable troponins has not been determined.

Measurement, Muscle proteins

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Missed diagnoses of acute coronary syndromes in the emergency room -- continuing challenges

Article Abstract:

Emergency room doctors can improve their ability to diagnose a heart attack by taking a detailed medical history and physical exam. Only about one-third of patients with chest pain are actually having a heart attack. Consequently, many patients with chest pain should not be admitted to a hospital. On the other hand, between 2% and 8% of patients having a heart attack are mistakenly discharged. It can be very difficult to diagnose a heart attack, but the creation of low-cost chest pain centers might be cost-effective.

Editorial

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