Evaluation of the patient with acute chest pain

Article Abstract:

Researchers have developed flowcharts that can be used to identify which patients with chest pain have a low, intermediate, or high risk of having a heart attack. An electrocardiogram (ECG) is the most important diagnostic procedure. Chest pain accompanied by abnormal changes on an ECG may signal a heart attack. Blood tests can detect chemicals that are released when heart muscle is injured. The most common test is for creatine kinase (CK). A newer test measures proteins called cardiac troponins. Some hospitals have constructed low-cost chest pain units where patients can be monitored without admitting them to the hospital.

Care and treatment

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Ruling out acute myocardial infarction: a prospective multicenter validation of a 12-hour strategy for patients at low risk

Article Abstract:

Economic pressures require that patients not be hospitalized if they do not need to be. However, it is not always simple to determine which patients need what. Heart attack is one example of such a diagnostic problem. Patients who are having a heart attack should be sent to a coronary care unit. Conversely, it is wasteful to send patients to a coronary care unit who are not having a heart attack. Previous research has suggested that when the diagnosis of heart attack is uncertain, a 24-hour observation period is appropriate. A true heart attack will progress; if there are no heart attack symptoms after 24 hours, the diagnosis of heart attack is very unlikely. However, patients may not be sent home during this 24-hour period, and so even patients who are ultimately found not to have heart attacks nevertheless take up time and space in the hospital. Using a statistical model, clinicians have developed a strategy for deciding which patients are at low risk of heart attack; their method requires only a 12-hour monitoring period, and thus helps conserve hospital resources. The model was evaluated with 771 patients who did not have enzyme abnormalities or recurrent pain (which are indicative of heart attack) during the first 12 hours of observation. Only three patients died of heart attacks, and in all three cases the attacks occurred at least three days after the observation period. Life-threatening conditions which were not fatal occurred in an additional three patients. Overall, the complications in this group were infrequent, indicating that the series of decisions determined by the model is appropriate for use in the evaluation of emergency room patients presenting with chest pain or signs of an apparent heart attack. (Consumer Summary produced by Reliance Medical Information, Inc.)

Methods, Management, Hospitalization, Medical protocols, Hospital care, Triage (Medicine)

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Prediction of the need for intensive care in patients who come to emergency departments with acute chest pain

Article Abstract:

Several risk factors have been identified that can predict the likelihood that a person with chest pain will require intensive care. Researchers studied 10,682 people who presented to an emergency department with chest pain to develop a model to predict which ones were likely to have a major cardiac event such as heart attack or further pain. This model was then validated on an additional set of 4,676 similar patients. The patients were assigned to risk groups ranging from low to high based on whether they had electrocardiographic evidence of ischemia, worsening pain, low blood pressure and abnormal lung sounds. Forty-one percent of the major cardiac events happened within 12 hours of admission and 62% occurred within 24 hours. By 72 hours after admission, 16% to 22% of the patients at high risk had a major cardiac event, compared to approximately 8% in the moderate risk group, 4% in the low risk group and less than 1% in the very low risk group. Low-risk patients could be admitted to low-intensity care units.

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