Abstract
The optimal diagnostic evaluation of patients presenting to the emergency department
(ED) with chest pain but without myocardial infarction or unstable angina is controversial.
We performed a prospective, nonrandomized, observational study of 1,195 consecutive
patients presenting to the ED with chest pain but who had normal or nondiagnostic
electrocardiograms and negative cardiac biomarkers. Patients (mean ± SD age 61 ± 15
years; 55% women) were admitted to the hospital and a standard protocol for evaluation
and treatment was suggested. The use of stress myocardial perfusion imaging (MPI)
or cardiac catheterization during their index hospitalization, and the 3-month incidence
of coronary angiography, percutaneous cardiac intervention, coronary artery bypass
surgery, re-presentation to our institution’s ED for chest pain, myocardial infarction,
or death were followed. Five hundred nine of 1,195 patients (43%) underwent provocative
stress MPI during their index hospitalization; 37% had perfusion defects (predominantly
ischemia). Fifty-six of 1,195 patients (4%) underwent cardiac catheterization without
stress MPI for their primary diagnostic evaluation. Six hundred thirty of 1,195 patients
(53%) had neither MPI or cardiac catheterization during their index hospitalization.
During the 3-month follow-up period, patients with a normal stress perfusion study
during their index hospitalization had fewer return visits (4%) compared with patients
with abnormal perfusion studies (19%), those who underwent catheterization directly
(16%), or patients with no initial diagnostic evaluation (15%) (p <0.001). In addition,
patients who had a diagnostic evaluation during their index hospitalization had a
lower incidence of either acute myocardial infarction (0.9% vs 2.1%) or death (0.4%
vs 3.0%, p <0.001) in the 3-month follow-up period. Accordingly, we strongly advocate
provocative stress MPI early after presentation for chest pain in all patients with
risk factors for coronary artery disease.
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to American Journal of CardiologyAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Emergency room technetium-99m sestamibi imaging to rule out acute myocardial events in patients with nondiagnostic electrocardiograms.J Am Coll Cardiol. 1993; 22: 1804-1808
- Technetium-99m sestamibi myocardial perfusion imaging in the emergency room evaluation of chest pain.J Am Coll Cardiol. 1994; 23: 1016-1022
- Comprehensive strategy for the evaluation and triage of the chest pain patient.Ann Emerg Med. 1997; 29: 116-125
- Clinical value of acute rest technetium-99m tetrofosmin tomographic myocardial perfusion imaging in patients with acute chest pain and nondiagnostic electrocardiograms.J Am Coll Cardiol. 1998; 31: 1011-1017
- Myocardial perfusion imaging for evaluation and triage of patients with suspected acute cardiac ischemia.JAMA. 2002; 288: 2693-2700
- Cost-effectiveness of mandatory stress testing in chest pain center patients.Ann Emerg Med. 1997; 29: 88-98
- Identification of patients at risk by graded exercise testing in an emergency department chest pain center.Am J Cardiol. 2000; 86: 289-292
- Comparison of 2-dimensional echocardiography and myocardial perfusion imaging for diagnosing myocardial infarction in emergency department patients.Am Heart J. 2002; 143: 659-667
- Evaluation of chest pain in patients with low to intermediate pretest probability of coronary artery disease by electron beam computed tomography.Am J Cardiol. 2000; 85: 283-288
- Massachusetts emergency medicine closed malpractice claims: 1988-1990.Ann Emerg Med. 1993; 22: 553-559
- Missed diagnoses of acute cardiac ischemia in the emergency department.N Engl J Med. 2000; 342: 1163-1170
- Normal limits for left ventricular ejection fraction and volumes estimated with gated myocardial perfusion imaging in subjects with normal exercise tests.J Nucl Cardiol. 2000; 7: 661-668
- Failure of right precordial electrocardiography during stress testing to identify coronary artery disease.J Nucl Cardiol. 2001; 8: 325-331
- An improved dobutamine protocol for myocardial perfusion imaging.Am J Cardiol. 2001; 88: 1303-1305
- Randomized comparison of a strategy of predischarge coronary angiography versus exercise testing in low-risk patients in a chest pain unit.J Am Coll Cardiol. 2001; 37: 2042-2049
- Selective use of single-photon emission computed tomography myocardial perfusion imaging in a chest pain center.Am J Cardiol. 2001; 87: 1351-1355
- Selective dual nuclear scanning in low-risk patients with chest pain to reliably identify and exclude acute coronary syndromes.Ann Emerg Med. 2001; 38: 207-215
- Evaluation of chest pain in low-risk patients presenting to the emergency department.Ann Emerg Med. 1998; 32: 1-7
Article info
Publication history
Accepted:
March 14,
2003
Received in revised form:
March 14,
2003
Received:
January 15,
2003
Identification
Copyright
© 2003 Excerpta Medica Inc. Published by Elsevier Inc. All rights reserved.
ScienceDirect
Access this article on ScienceDirectLinked Article
- Evaluation of patients with chest painAmerican Journal of CardiologyVol. 93Issue 1