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• Stephen W. Smith, MD
Chest Pain
No one factor can allow safe discharge
• History of pain
•Rest Sestamibi
• Demographics: age,
•Serial troponins
sex
•Stress echo
• Past Hx: CAD, risk •Stress sestamibi
factors •CT angio
• ECG •Angiography
• Initial Biomarkers
(troponin)
Endpoints for diagnosing ACS
• Death
• MI
• Revascularization
– Done for significant stenosis
– Stenosis can be present without ACS
– Injury biomarkers (e.g., Troponin) cannot
detect stenosis
Case
• 40 yo with substernal chest pressure for 3
hours
• No radiation or associated symptoms
• Ongoing, not intermittent
• No cardiac history
• Cigarette smoker, no other risks
• ECG normal
• First trop < .04
Lee Goldman
Ann Int Med 2003; 139:987
$124 per
patient cost
savings
4.5% MI 0.4% MI
miss rate miss rate
Graff: Am J Cardiol, Volume 80(5):563-568, 9/1/1997
Risk factors for complications
death, MI, CHF, shock, v fib, v tach
• EKG:
– ST elevation > ST depression > T wave inversion
– Normal has lower risk of complications, even if MI present
• h/o recent MI
• Rales above the bases
• Pain
– worse than previous angina
– Same as prior MI
• BP < 110
• DM
• Active or recurrent pain
Brush JE et al. NEJM 312:1137-1141, 1985. Karlson BW et al. Eur Heart
J 15:1558-65, 1994. Yusuf S et al. Eur heart J 5:690-96, 1984.
Patients with Acute MI sent home from the ED
Multicenter Chest Pain Study
Lee TH., et al. Clinical characteristics and natural history of patients with acute
myocardial infarction sent home from the emergency room. Am J Cardiol 1987;
60:219-24.
• Old Q-waves
• ST-T abnormalities secondary to abnormal
depolarization (i.e., abnormal QRS, e.g., LVH)
• Minor, non-dynamic ST or T-wave abnormalities,
such as ST depression < 1 mm and T-wave
flattening or inversion < 1 mm
– not otherwise explained
• May be changed from previous ECG, but is not
specific for ischemia or infarction
Sensitivity and specificity of ECG
for MI as diagnosed by CK-MB
• CP 11,805
• AMI 1962
• Diagnostic ECG 2979 (STEMI or UA/NSTEMI)
• nl ECG 3635
• nl ECG & AMI 125 (6.4% of AMI, 3.4% of nl ECG,
1.1% of all pts with CP)
• NS ECG 5191
• NS ECG & AMI 442 (23% of AMI, 9% of NS ECG,
3.7% of all pts. with CP)
• Nl or NS ECG 8826
• Nl or NS ECG & AMI 567 (29% of all AMI, 6.4% of all nl or NS
ECG, 4.8% of all pts with CP)
Diagnostic vs. nondiagnostic (“nonspecific”) ECG
MI Diagnosis by CK-MB (Trop)
• Approx 45% (25%) of AMI has diagnostic STE
• Approx 26% (15%) of AMI has diagnostic ST
depression or T-wave inversion
• Approx 23% (50%) of AMI is abnormal but
nondiagnostic
– 8-15% some evidence of ischemia or infarction not
known to be old
• Approx 6% (10%) of AMI has normal ECG
– Hickan DH, Sox HC, Sox CH. Systematic bias in recording the
history in patients with chest pain. J Chronic Dis. 1985;38:91-100.
– Gadsboll N, et al. Symptoms and signs of heart failure in patients
with myocardial infarction: reproducibility and relationship to chest
x-ray, radionuclide ventriculography and right heart catheterization.
Eur Heart J. 1989;10:1017-1028.
Risk of MI with Chest Pain
Lee TH, et al. Acute chest pain in the emergency room.
Identification and examination of low-risk patients. Arch Int
Med 1985; 145:65-69
• Age
• Sex
• presence of chest pain
• chest pain as the chief symptom
• a history of heart attack or nitroglycerine use
• ST-segment or T-wave abnormalities
• Presence of Q waves
Acute cardiac ischemia time-insensitive predictive instrument (ACI-
TIPI) electrocardiogram. Selker: Ann Intern Med, Volume
129(11).December 1, 1998.845-855
ACI-TIPI
Used at several hospitals, compared to
months when not available
Risk factors:
1) BP < 110 mm Hg
2) Rales above bases
bilaterally
3) Known unstable ischemic
heart disease
---worsening of previously
stable angina
---new onset of postinfarction
angina
---angina after a coronary-
revascularization procedure
4) Pain the same as that
associated with a prior
myocardial infarction.
Total 6802
Admitted* 3596 (53%)
cTnI drawn 3779 (56%)
cTnI drawn and patient admitted** 3343 (49%)