Chest Pain in the Emergency Room: A Solved Problem

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Abstract

Background

TheIntensive Diagnosis Unit (IDU) was designed to improve the management of patients with acute

chest pain in the Emergency Room.

Objective

To determine the diagnostic performance of the pathway applied on patients with a doubtful initial diagnosis.

Methods Of 1800 consecutive patients with acute chest pain, 30% had an initial diagnosis of "doubtful" acute coronary syndrome (doubtful angina plus EKG without ischemic changes); 350 patients (20%) were admitted into the IDU and were evaluated withEKG and serum markers (CK, MB-CK, T troponin)during 8 hours, according to the time of chest pain on set; after that, a functional evaluation was performed due to differences in medical approach and feasibility. Two groups were defined: discharged ambulatory patients and admitted patients after initial evaluation. Events were evaluated in the follow-up until thirty days in the first group and at hospital discharge in the second group. Sensitivity, specificity, positive(PPV) and negative predictive value (NPV) were calculated for the diagnosis of definite acute coronary syndrome. Results Three hundred and eight patients (88%) were discharged home after 13±7hours of evaluation; there were 3 events in the follow-up. The remaining 42(12%) were definitely admitted after 8 ± 5 hours.The diagnosis at hospital discharge confirmed the admission diagnosis in 88% of patients. Sensitivity was 92%, specificity 98%, PPV 85% and NPV 99%. Conclusion The strategy was useful to manage patients with an initial "doubtful" acute coronary syndrome.Due to high prevalence of chest pain patients, incorporation of this kind of routine could have a great clinical impact, avoiding unnecessary admissions and the unintentional release from the ER of patients with an acute coronary syndrome.