Missed Diagnoses of Acute Cardiac Ischemia in the Emergency Department

Pope, Hector J.; Aufderheide, Tom P.; Ruthazer, Robin; Woolard, Robert; Feldman, James A.; Beshansky, Joni R.; Griffith, John L.; Selker, Harry P.

doi:10.1097/00132586-200012000-00011

Cited by 356 publications

(462 citation statements)

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“…Between 2 and 13% of patients with acute myocardial infarction (MI) are discharged from emergency departments with an incorrect diagnosis. [3][4][5] Accurate triage of patients provides effective risk stratification, which maximizes patient benefit by directing more aggressive therapy to those patients at higher risk while minimizing the known risks that occur when inappropriate diagnosis, treatment, or discharge occurs. Our understanding and treatment of ACS continues to evolve with the recognition that a wide range of disease presentations exists.…”

Section: Introductionmentioning

confidence: 99%

A population‐based evaluation of the thrombolysis in myocardial infarction risk score for unstable angina and non‐ST elevation myocardial infarction

Bartholomew

Sheps

Monroe

et al. 2004

Clinical Cardiology

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SummaryBackground: The Thrombolysis in Myocardial Infarction risk score (TIMI-RS) for unstable angina/non-ST elevation myocardial infarction (MI) was developed in patients presenting with unstable angina accompanied by high-risk features or non-ST elevation MI to determine early risk stratification.Hypothesis: The validity in patients presenting for emergency care with symptoms suggestive of acute coronary syndrome (ACS) has not been well established, and the present study sought to do so by evaluating the TIMI-RS in a prospective fashion.Methods: A prospective TIMI-RS using seven variables was calculated in 245 patients admitted to the hospital with symptoms suggestive of ACS: (1) age > 65, (2) three or more cardiac risk factors, (3) ST deviation, (4) aspirin use within 7 days, (5) two or more anginal events over 24 h, (6) history of coronary stenosis, and (7) elevated troponin. Patients were contacted at 30 days and data were collected concerning major adverse cardiac events.Results: In patients presenting with chest pain, a higher TIMI-RS was associated with an increase in major adverse cardiac events within 30 days. We found that the 30-day event rate was 0% for a score of 1, 20% for a score of 2, 24% for a score of 3, 42% for a score of 4, 52% for a score of 5, and 70% for a score of 6 or 7 (p < 0.0001).

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Section: Introductionmentioning

confidence: 99%

A population‐based evaluation of the thrombolysis in myocardial infarction risk score for unstable angina and non‐ST elevation myocardial infarction

Bartholomew

Sheps

Monroe

et al. 2004

Clinical Cardiology

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“…A large proportion of patients who present to emergency departments with chest pain has non-cardiac diagnoses, and most of these would be, most appropriately, discharged directly home. In practice, a small, but significant, proportion of patients is sent home inappropriately [14] leading to potentially serious clinical errors and litigation. On the other hand, many relatively low-risk patients are inappropriately admitted to telemetry and high dependency units to rule out acute cardiac ischaemia [15].…”

Section: Clinical Motivationmentioning

confidence: 99%

Automatic covariate selection in logistic models for chest pain diagnosis: A new approach

Harrison

Kennedy

2008

Computer Methods and Programs in Biomedicine

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A newly established method for optimizing logistic models via a minorizationmajorization procedure is applied to the problem of diagnosing acute coronary syndromes (ACS). The method provides a principled approach to the selection of covariates which would otherwise require the use of a suboptimal method owing to the size of the covariate set. A strategy for building models is proposed and two models optimized for performance and for simplicity are derived via ten-fold crossvalidation. These models confirm that a relatively small set of covariates including clinical and electrocardiographic features can be used successfully in this task.The performance of the models is comparable with previously published models using less principled selection methods. The models prove to be portable when tested on data gathered from three other sites. Whilst diagnostic accuracy and calibration diminishes slightly for these new settings, it remains satisfactory overall.The prospect of building predictive models that are as simple as possible for a required level of performance is valuable if data-driven decision aids are to gain wide acceptance in the clinical situation owing to the need to minimize the time taken to gather and enter data at the bedside.

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“…Among these patients, approximately one-third presented electrocardiographic (ECG) changes suggestive of acute myocardial ischemia; however, approximately one-half of patients with acute myocardial infarction do not show any diagnostic ECG changes at presentation [1][2][3]. Of note, up to 5% of patients without diagnostic ECG changes sent home turn out to be affected by acute myocardial infarction; mortality rate among this population resulted 2 times higher than patients identified and treated, with legal consequences [3].…”

Section: Introductionmentioning

confidence: 96%

Short- and long-term cardiac events in patients with chest pain with or without known existing coronary disease presenting normal electrocardiogram

Conti

Poggioni

Viviani

et al. 2012

The American Journal of Emergency Medicine

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Aim: The aim of this study is to evaluate incidence of adverse cardiac events in patients with chest pain with or without known existing coronary disease presenting normal electrocardiogram (ECG) and initial troponin. Methods: Prospective, nonrandomized study enrolled low-risk patients with normal ECG and troponin on admission who underwent observation and/or stress testing by unstandardized clinical judgment. Patients who experienced recurrent angina or positive ECGs or positive troponins during observation or patients with positive stress testing were admitted; otherwise, they were discharged. End Point: The end points are cardiac events at short-and long-term follow-up including cardiovascular death, myocardial infarction, unstable angina, and revascularization. Results: Of 5656 patients considered, 1732 with ischemic ECG were initially admitted and, therefore, excluded from the analysis; 2860 with pleuritic chest pain and normal ECG were discharged; 1064 with visceral chest pain and normal ECG were enrolled. Patients with known coronary disease (45%) were older and likely presented known vascular disease. Patients with known vascular disease, older age, female sex, diabetes mellitus, and lower chest pain score were likely managed with observation. In patients with known coronary disease as compared with patients without, overall cardiac events account for 35% vs 14%, respectively (P b .001), as follows: in-hospital, 23% vs 10%, (P b .001); 1 month, 4% vs 2% (P = .133); and 9.9 ± 4.9 months, 8% vs 2%, respectively (P b .001). Conclusions: One-third of patients with chest pain with known coronary disease, negative ECG, and biomarkers were subsequently found to have adverse cardiac events. The value of this research for an emergency medicine audience could be extended to all clinicians and general practitioners beyond cardiologists.

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Missed Diagnoses of Acute Cardiac Ischemia in the Emergency Department

Cited by 356 publications

References 0 publications

A population‐based evaluation of the thrombolysis in myocardial infarction risk score for unstable angina and non‐ST elevation myocardial infarction

A population‐based evaluation of the thrombolysis in myocardial infarction risk score for unstable angina and non‐ST elevation myocardial infarction

Automatic covariate selection in logistic models for chest pain diagnosis: A new approach

Short- and long-term cardiac events in patients with chest pain with or without known existing coronary disease presenting normal electrocardiogram

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