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Identification of Acute Cardiac Ischemia in the Emergency Department

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Part of the book series: Developments in Cardiovascular Medicine ((DICM,volume 193))

Abstract

Chest pain and other symptoms suggestive of acute cardiac ischemia (ACI, including acute myocardial infarction [AMI] and unstable angina pectoris) account for over 6 million emergency department (ED) visits per year. Of these, the approximately 30% who truly have ACI (just under half of whom will prove to have AMI) [1] must be quickly and accurately separated from the majority of ED patients who do not have ACI and then promptly treated and admitted to the hospital. This is not an easy task, the environment in which this must be done is not often optimal, and there are no perfect tests that completely handle all possible cases. However, as reviewed in this chapter, there are a number of tests and strategies, that, when combined with good clinical judgement, can be of significant assistance.

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References

  1. Selker HP, Griffith JL, D’Agostino RB. A tool for judging coronary tare unit admission that is appropriate for both real-time and retrospective use: A timeinsensitive predictive instrument (TIPI) for acute cardiac ischemia: A multicenter study. Med Care 29:610, 1991.

    Article  PubMed  CAS  Google Scholar 

  2. Pozen MW, D’Agostino RB, Selker HP, Sytkowski PA, Hood WB. A predictive instrument to improve coronary care unit admission practices in acute ischemic heart disease. N Engl J Med 310:1273, 1984.

    Article  PubMed  CAS  Google Scholar 

  3. Schor S, Behar S, Modan B, Barell V, Drory J, Kariv I. Disposition of presumed coronary patients from an emergency room. A follow-up study. JAMA 236:941, 1976.

    Article  PubMed  CAS  Google Scholar 

  4. Lee TH, Rouan GW, Weisberg MC, Brand DA, Acampora D, Stasiulewicz C, Walshon J, Terranova G, Gottlieb I, Goldstein-Wayne B. Clinical characteristics and natural history of patients with acute myocardial infarction sent home from the emergency room. Am J Carciol 60:219, 1987.

    Article  CAS  Google Scholar 

  5. McCarthy BD, Beshansky JR, D’Agostino RB, Selker HP. Missed diagnoses of acute myocardial infarction in the emergency department: Results from a multicenter study. Ann Emerg Med 22:579, 1993.

    Article  PubMed  CAS  Google Scholar 

  6. McCarthy BD, Wong JB, Selker HP. Detecting acute cardiac ischemia in the emergency department: A review of the lirerature. J Gen Intern Med 5:365, 1990.

    Article  PubMed  CAS  Google Scholar 

  7. Fineberg HV, Scadden D, Goldman L. Care of patients with a low probability of acute myocardial infarction: Cost-effectiveness of alternatives to coronary-care-unit admission. N Engl J Med 310:1301, 1984.

    Article  PubMed  CAS  Google Scholar 

  8. Fuchs R, Scheidt S. Improved criteria for admission to cardiac care units. JAMA 246:037, 1981.

    Article  Google Scholar 

  9. Nattel S, Warnica JW, Ogilvie RI. indications for admission to a coronary care unit in patients with unstable angina. Can Med Assoc J 122:180, 1980.

    PubMed  CAS  Google Scholar 

  10. Eisenberg JM, Horowitz LN, Busch R, Arvan D, Rawnsley H. Diagnosis of acute myocardial infarction in the ER: A prospective assessment of clinical decision making and the usefulness of immediate cardiac enzyme determination. J Commun Health 4:190, 1979.

    Article  CAS  Google Scholar 

  11. Seager SB. Cardiac enzymes in the evaluation of chest pain. Ann Emerg Med 9:346, 1980.

    Article  PubMed  CAS  Google Scholar 

  12. Horowitz RS, Morganroth J. Immediate detection of early high-risk patients with an acute myocardial infarction using two-dimensional echocardiographic evaluation of left ventricular regional wall motion abnormalities. Am Heart J 103:814, 1982.

    Article  PubMed  CAS  Google Scholar 

  13. Wackers FJ, Lic KI, Liem KL, Sokole EB, Samson G, van der Schoot J, Durrer D. Potential value of thaIlium-201 scintigraphy as a means of selecting patients for the coronary care unit. Br Heart J 41:111, 1979.

    Article  PubMed  CAS  Google Scholar 

  14. Gibbons RJ, Verani MS, Behrenbeck T, Pellikka PA, O’Connor MK, Mahmarian JJ, Chesebro JH, Wackers FJ. Feasibility of tomographic 99m-Tc-hexakis-2-methoxy-2-methylpropyl-isonitrile imaging for the assessment of myocardial area at risk and the effect of treatment in acute myocardial infarction. Circulation 80:1277, 1989.

    PubMed  CAS  Google Scholar 

  15. Bilodeau I, Theroux P, Gregoire J, Gagnon D, Arsenault A. Technetium-99m sestamibi tomography in patients with spontaneous chest pain: Correlations wich clinical, electrocardiographic and angiographie findings. J Am Coll Cardiol 18:1684, 1991.

    PubMed  CAS  Google Scholar 

  16. Verani MS. Technetium-99m sestamibi imaging in acute ischemie syndromes. Prim Cardiol 18:56, 1992.

    Google Scholar 

  17. Varetto T, Cantalupi D, Altieri A, Orlandi C. Emergency room technetium-99m sestamibi imaging to rule out acute myocardial ischemie events in patients with nondiagnostic electrocardiography. J Am Coll Cardiol 22:1804, 1993.

    PubMed  CAS  Google Scholar 

  18. Varetto T, De Cicco Cantalupi D, Altieri A, Leone G, Devoti G, Orlandi C. Tc99m sestamibi perfusion imaging allows detection of unstable angina after chest pain remission. Circulation 86:146, 1992.

    Google Scholar 

  19. Goldman L, Cook EF, Brand DA, Lce TH, Rouan GW, Weisberg MC, Acampora D, Stasiulewicz C, Walshon J, Terranova G. A computer protocol to predict myocardial infarction in emergency department patients with chest pain. N Engl J Med 318:797, 1988.

    Article  PubMed  CAS  Google Scholar 

  20. Ticrney WM, Roth BJ, Psaty B, McHenry R, Fitzgerald J, Stump DL, Anderson FK, Ryder KW, McDonald CJ, Smith DM. Predictors of myocardial infarction in emergency room patients. Crit Care Med 13:526, 1985.

    Article  Google Scholar 

  21. Baxt WG. Use of an artificial neural network for the diagnosis of myocardial infarction. Ann Intern Med 115:843, 1991.

    PubMed  CAS  Google Scholar 

  22. Selker HP, Griffith JL, Patil S, Long WJ, D’Agostino RB. A comparison of performance of mathematical predictive methods for medical diagnosis: Identifying acute cardiac ischemia among emergency department patients. J Invest Med 4.3:468, 1995.

    Google Scholar 

  23. Pozen MW, D’Agostino RB, Mitchell JB, Selker HP, Sytkowski PA, Hood WB. The usefulness of a predictive instrument to reduce inappropriate admissions to the coronary care unit. Ann Intern Med 92:238, 1980.

    PubMed  CAS  Google Scholar 

  24. Rifkin RD, Hood WB Jr. Bayesian analysis of electrocardiographic exercise stress testing. N Engl J Med 297:681, 1979.

    Article  Google Scholar 

  25. Kinlen LJ. Incidence and presentation of myocardial infarction in an English community. Br Heart J 35:616, 1973.

    Article  PubMed  CAS  Google Scholar 

  26. Margolis JR, Kannel WB, Feinleib M, Dawber TR, McNamara PM. Clinical features of unrecognized myocardial infarction-silent and symptomatic. Eighteen year follow-up: The Framingham Study. Am J Cardiol 32:1, 1973.

    Article  PubMed  CAS  Google Scholar 

  27. Uretsky BE, Farquhar DS, Berezin AF, Hood WB Jr. Symptomatic myocardial infarction without chest pain: Prevalence and clinical course. Am J Cardiol 40:498, 1977.

    Article  PubMed  CAS  Google Scholar 

  28. Goldman L, Weinberg M, Weisberg M, Olshen R, Cook EF, Sargent RK, Lamas GA, Dennis C, Wilson C, Deckelbaum L, Fineberg H, Stiratelli R. A computer-derived protocol to aid in the diagnosis of ER patients with acute chest pain. N Engl J Med 307:588, 1982.

    Article  PubMed  CAS  Google Scholar 

  29. Russell RO, et al Unstable angina pectoris: National Cooperative Study Group to compare medical and surgical therapy: IV. Results in patient with left anterior descending coronary artery disease. Am J Cardiol 48:517, 1981.

    Article  Google Scholar 

  30. Krause KR, Hutter AM Jr, DeSanctis RW. Acute coronary insufficiency. Course and follow-up. Circulation 45/46(Suppl. I): 166, 1972.

    Google Scholar 

  31. Selker, HP. Coronary care unit triage decision aids: How do we know when they work? Am J Med 87:491, 1989.

    Article  PubMed  CAS  Google Scholar 

  32. Heberden W. Some account of disorder of the breast. Med Trans R Coll Phys Lond, 1772.

    Google Scholar 

  33. Herrick JB. Clinical features of sudden obstruction of the coronary arteries. JAMA 199:156, 1912.

    Google Scholar 

  34. Lee TH, Cook F, Weisberg M, Sargent RK, Wilson C, Goldman L. Acute chest pain in the emergency room: Identification and examination of low risk patients. Arch Intern Med 145:65, 1985.

    Article  PubMed  CAS  Google Scholar 

  35. Jayes RL, Beshansky JR, D’Agostino RB, Selker HP. Do patients’ coronary risk factor reports predict acute cardiac disease in the Emergency Department? A mukicenter study. J Clin Epidemiol 45:621, 1992.

    Article  PubMed  Google Scholar 

  36. Behar S, Schor S, Kariv I, Barell V, Modan B. Evaluation ot electrocardiogram in emergency room as a decision-making tool. Chest 71:486, 1977.

    Article  PubMed  CAS  Google Scholar 

  37. Rude RE, Poole WK, Muller JE, Turi Z, Rutherford J, Parker C, Roberts R, Raabe DS Jr, Gold HK, Stone PH. Electrocardiographic and clinical criteria for recognition of acute myocardial infarction based on analysis of 3697 patients. Am J Cardiol 52:936, 1983.

    Article  PubMed  CAS  Google Scholar 

  38. Jayes RL, Larsen GC, Beshansky JR, D’Agostino RB, Selker HP. Physician electrocardiogram reading in the emergency department: Accuracy and effect on triage decisions — findings from a mukicenter study. J Gen Intern Med 7:387, 1992.

    Article  PubMed  Google Scholar 

  39. Larsen GC, Griffith JL, Beshansky JR, D’Agostino RB, Selker HP. Electrocardiographic left ventricular hypertrophy in patients with suspected acute cardiac ischemia — Its influence on diagnosis, triage, and short term prognosis: A mukicenter study. J Gen Intern Med 9:666, 1994.

    Article  PubMed  CAS  Google Scholar 

  40. Zalenski RJ, Cooke D, Rydman R, Sloan EP, Murphy DG. Assessing the diagnostic value of an ECG containing leads V+R+,V8+ and V9: The 15 lead ECG. Ann Emerg Med 22:786, 1993.

    CAS  Google Scholar 

  41. Zalenski RJ, Rydman R, Sloan E, Hahn K, Cooke D, Fagan J, Fligner DJ, Hessions W, Justis D, Kampe LM, Shah S, Tucker J, Zwicke D. Value of posterior and right ventricular leads in comparison to the standard 12-lead electrocardiogram in evaluation ot ST segment elevation in suspected acute myocardial infarction. Am J Cardiol 79, 1997 in press.

    Google Scholar 

  42. Zehender M, Kasper W, Kauder E, Geibel A, Schonthaler M, Olschewski M, Just H. Right ventricular infarction as an independent predictor of prognosis after acute inferior myocardial infarction. N Engl J Med 328:981, 1993.

    Article  PubMed  CAS  Google Scholar 

  43. Zehender M, Kasper W, Kauder E, Geibel A, Schonthaler M, Olschewski M, Just H. Eligibility for and benefit of thrombolytic therapy in inferior myocardial infarction: Focus on the prognostic importance of right ventricular infarction. J Am Coll Cardiol 24:362, 1994.

    PubMed  CAS  Google Scholar 

  44. Hedges JR, Young GP, Henkel GF, Gibier WB, Green TR, Swanson JR. Serial ECGs are less accurated than serial CK-MB results for emergency department diagnosis of myocardial infartion. Ann Emeg Med 21:1445, 1992.

    Article  CAS  Google Scholar 

  45. Sharkey SW, Berger CR, Brunette DD, Hentry TD. Impact of the electrocardiogram on the delivery of thrombolytic therapy for acute myocardial infarction. Am J Cardiol 73:550, 1994.

    Article  PubMed  CAS  Google Scholar 

  46. Gibier WB, Runyon JP, Levy RC, Sayre MR, Kacich R, Hattemer CR, Hamilton C, Gerlach JW, Walsh RA. A rapid diagnostic treatment center for patients with chest pain in the emergency depratment. Ann Emerg Med 25:1, 1995.

    Article  Google Scholar 

  47. Gaspoz JM, Lee TH, Cook EF, Weisberg MC, Goldman L. Outcome of patiens who were admitted to a new short-stay unit to rule-out AMI. Am J Cardiol 68:145, 1991.

    Article  PubMed  CAS  Google Scholar 

  48. Kerns JR, Shaub TF, Fontanarosa PB. Emergency cardiac stress testing in the evaluation of emergency department patients with atypical chest pain. Ann Emetg Med 22:794, 1993.

    Article  CAS  Google Scholar 

  49. Tsakonis JS, Shesser R, Rosenthal R, Bittar GD, Smith M, Wasserman AG. Safety of immediate treadmill testing in selected emergency department patients with chest pain — a preliminary report. Am J Emerg Med 9:557, 1991.

    Article  PubMed  CAS  Google Scholar 

  50. Lewis WR, Amsterdam EA. Utility and safety ot immediate exercise testing of low-risk patients admitted to the hospital for suspected acute myocardial infarction. Am J Cardiol 74:987, 1994.

    Article  PubMed  CAS  Google Scholar 

  51. Zalenski RJ, McCarren M, Roberts R, Rydman RJ, Jovanovic B, Das K, Mendez J, EI-Khadra M, Fraker L, McDermott M. An evaluation of an emergency department chest pain diagnostic protocol to exclude acute myocardial infarction and ischemia. Arch Intern Med 157, 1997, in press.

    Google Scholar 

  52. Selker H, Zalenski R, Antman E, Aufderheide T, Bernard S, Bonow R, Gibier WB, Hagen M, Johnson P, Lau J, McNutt R, Ornato J, Schwartz JS, Scott J, Tunick P, Weaver WD. Working Group of the National Heart Attack Alett Program, National Heart Lung and Blood Institute, National Institutes of Health. An evaluation of technologies for identifying acute cardiac ischemia in the Emergency Department. Ann Emerg Med 29:13, 1997.

    Article  PubMed  CAS  Google Scholar 

  53. Puleo PR, Meyer D, Wathen C, Tawa CB, Wheceler S, Hamburg RJ, Ali N, Obermueller SD, Triana JF, Zimmerman JL. Use of a rapid assay of subforms of creatine kinase MB to diagnose of rule out acute myocardial infarction. N Engl J Med 331:561, 1994.

    Article  PubMed  CAS  Google Scholar 

  54. Gibier WB, Lewis LM, Erb RE, Makens PK, Kaplan BC, Vaughn RH, Biagini AV, Blanton JD, Campbell WB. Earlv detection of acute myocardial infarction in patients presenting with chest pain and non-diagnostic ECGs: Serial CK-MB sampling in the emergency department. Ann Emerg Med 19:1359, 1990; erratum 20:420, 1991.

    Article  Google Scholar 

  55. Gibier WB, Young GP, Hedges JR, Lewis LM, Smith MS, Carleton SC, Aghababian RV, Jorden RO, Allison EJ, Otten EJ, Makens PK, Hamilton C. Acute myocardial infarction in chest pain patients with nondiagnostic ECGs: Serial CK-MB sampling in the emergency department. Ann Emerg Med 2:504, 1992.

    Google Scholar 

  56. Lee TH, Juarez G, Cook EF, Weisberg MC, Rouan GW, Brand DA, Goldman L. Ruling out acute myocardial infarction: A prospective multicenter validation of a 12-hour strategy for patients at low risk. N Engl J Med 324:1239, 1991.

    Article  PubMed  CAS  Google Scholar 

  57. deWinter RJ, Koster RW, Sturk A, Sanders GT. Value of myoglobin, troponin T, and CK-MBmass in ruling our an acute myocardial infarction in the emergency department. Circulation 92:3401, 1995.

    Google Scholar 

  58. Viskin S, Heller K, Gheva D, Hassner A, Shapira I, Meyer M, Sarfatti E, Lucksman D, Shi holer S. The importance of creatine kinase determination in identifying acute myocardial infarction among patients complaining of chest pain in an emergency room+. Cardiology 74:100, 1987.

    Article  PubMed  CAS  Google Scholar 

  59. Lee TH, Weinberg M, Cook F, Daley K, Brand DA, Goldman L. Evaluation of creatine kinase and creatine kinase-MB for diagnosing myocardial infarction: Clinical impact in the emergency room. Arch Intern Med 147:115, 1987.

    Article  PubMed  CAS  Google Scholar 

  60. Marin MM, Teichman SL. Use of rapid serial sampling of creatine kinase MB for very early detection of myocardial infarction of patients with acute chest pain. Am Heart J 123:354, 1992.

    Article  PubMed  CAS  Google Scholar 

  61. Antman EM, Tanasijevic MJ, Thompson B, Schactman M, McCabe CH, Cannon CP, Fischer GA, Fung AY, Thompson C, Wycnga D, Braunwald E. N Engl J Med 335:1342, 1996.

    Article  PubMed  CAS  Google Scholar 

  62. Ohman EM, Armstrong PW, Christenson RH, Granger CB, Katus HA, Hamm CW, O’Hanesian MA, Wagner GS, Kiciman NS, Harrell FE, Califf RM, Topol EJ. Cardiac troponin T levels for risk stratification in acute stratification in acute myocardial ischemia. N Engl J Med 335:1333, 1996.

    Article  PubMed  CAS  Google Scholar 

  63. Strauss HW, Harrison K, Langan JK, Lebowitz E, Pitt B. Thallium-201 for myocardial imaging: Relation of thallium-201 to regional myocardial perfusion. Circulation 51:641, 1975.

    PubMed  CAS  Google Scholar 

  64. Wackers FJ, Sokole EB, Samson G, Schoot JB, Lie KL, Wellens HJ. Value and limitations of thallium-201 scintigraphy in the acute phase of myocardial infarction. N Engl J Med 295:1, 1976.

    Article  PubMed  CAS  Google Scholar 

  65. Wackers FJ, Lie KI, Liem KL, Sokole EB, Samson G, van der School JB, Durrer D. Thallium-201 scintigraphy in unstable angina pectoris. Circulation 57:738, 1978.

    PubMed  CAS  Google Scholar 

  66. Okada RD, Glover D, Gaffney T, Williams S. Myocardial kinetics of technetium-99m-hexakis-2-methoxy-2-methylpropyl-isonitri Ic. Circulation 77:491, 1988.

    PubMed  CAS  Google Scholar 

  67. Hauser AM, Gangadharan V, Ramos R, Gordon S, Timmis GC. Sequence of mechanical, electrocardiographic and clinical effects of repeated coronary artery occlusion in human beings: Echocardiographic observations during coronary angioplasty. J Am Coll Cardiol 5:193, 1985.

    PubMed  CAS  Google Scholar 

  68. Peels CH, Visser CA, Kupper AJF, Visser FC, Roos J P. Usefulness of two-dimensional echocardiography for immediate detection of myocardial ischemia in the emergency room. Am J Cardiol 65:687, 1990.

    Article  PubMed  CAS  Google Scholar 

  69. Sasaki H, Charuzi Y, Beeder C, Sugiki Y, Lew AS. Utility of echocardiography for the early assessment of patients with non-diagnostic chest pain. Am Heart J 112:494, 1986.

    Article  PubMed  CAS  Google Scholar 

  70. Sabia P, Abbott RD, Afrooktch A, Keller MW, Touchstone DA, Kaul S. Value of regional wall motion abnormality in the emergency room diagnosis of acute myocardial infarction. Circulation 84:185, 1991.

    Google Scholar 

  71. Loh IK, Charuzi Y, Beeder C, Marshall LA, Ginsburg JH. Early diagnosis of non-rransmural myocardial infarction by two-dimensional echocardiography. Am Heart J 104:963, 1982.

    Article  PubMed  CAS  Google Scholar 

  72. McNutt RA, Selker HP. How did the acute ischemic heart disease predictive instrument reduce unnecessary coronary care unit admissions? Med Decis Making 8:90, 1988.

    Article  PubMed  CAS  Google Scholar 

  73. Wasson JH, Sox HC, Neff RK, Goldman L. Clinical prediction rules: Applications and methodological standatds. N Engl J Med 313:793, 1985.

    Article  PubMed  CAS  Google Scholar 

  74. Sawe U. Early diagnosis of acute myocardial infarction with special reference to the diagnosis of the intermediate coronary syndrome: A clinical study. Acta Med Stand 520(Suppl.):176, 1972.

    Google Scholar 

  75. Lee TH, Pearson SD, Johnson PA, Garcia TB, Weisberg MC. Guadagnoli E, Cook EF, Goldman L. Failure of information as an intervention to modify clinical management: A cime-series trial in patients with acute chest pain. Ann Intern Med 122:4.34, 1995.

    Google Scholar 

  76. Selker HP, D’Agostino RB, Laks MM. A predictive instrument for acute ischemic heart disease to improve coronary care unit admission practices: A potential on-line tool in a computerized electrocardiograph. J Electrocardiol 88:S11, 1988.

    Article  Google Scholar 

  77. Van der Does E, Lubsen J, Pool J. Acute coronary events in a general practice: Objectives and design of the Imminent Myocardial Infarction Rotterdam Study. Heart Bull 7:91, 1976.

    Google Scholar 

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Selker, H.P., Zalenski, R.J. (1997). Identification of Acute Cardiac Ischemia in the Emergency Department. In: Becker, R.C. (eds) Textbook of Coronary Thrombosis and Thrombolysis. Developments in Cardiovascular Medicine, vol 193. Springer, Boston, MA. https://doi.org/10.1007/978-0-585-33754-8_26

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