Introduction:It is often believed that chest pain relieved by nitroglycerin is indicative of coronary artery disease origin. Objective: To determine if relief of chest pain with nitroglycerin can be used as a diagnostic test to help differentiate cardiac chest pain and non-cardiac chest pain. Design: Prospective observational cohort study with a 4-week follow-up of patients enrolled. Setting: Academic tertiary care hospital, with 60 000 visits/year. Inclusion criteria: Adult patients presenting to the emergency department with active chest pain who received nitroglycerin and were admitted for chest pain. Exclusion criteria: Patients with acute myocardial infarction diagnosed after obtaining an ECG, patients whose chest pain could not be quantified, those for whom no cardiac work-up was done, or those who received emergent cardiac catheterization. Results: 270 patients were enrolled. Nitroglycerin relieved chest pain in 66% of the subjects. The diagnostic sensitivity of nitroglycerin to determine cardiac chest pain was 72% (64%-80%), and the specificity was 37% (34%-41%). The positive likelihood ratio for having coronary artery disease if nitroglycerin relieved chest pain was 1.1 (0.96-1.34). Telephone follow-up at 4 weeks was performed, with a 95% follow-up rate. Conclusions: Relief of chest pain with nitroglycerin is not a reliable diagnostic test and does not distinguish between cardiac and non-cardiac chest pain. RÉSUMÉ Introduction :On croit souvent que la douleur thoracique soulagée par la nitroglycérine indique que cette douleur est attribuable à une insuffisance coronarienne. Objectif : Déterminer si le soulagement de la douleur thoracique à l'aide de la nitroglycérine peut servir de test diagnostique permettant de différencier la douleur thoracique d'origine cardiaque de la douleur d'origine non cardiaque. Méthodologie : Étude prospective par observation de cohortes avec un suivi après 4 semaines des patients inclus dans l'étude. Cadre : Hôpital universitaire de soins tertiaires recevant 60 000 visites/année. Critères d'inclusion : Les patients adultes s'étant présentés à l'urgence pour une douleur tho- ORIGINAL RESEARCH • RECHERCHE ORIGINALE ADVANCES
Introduction: It is commonly believed that chest pain relieved by taking nitroglycerin (NTG) is caused by active coronary artery disease (CAD). Is this medical myth or is this true? Objective: To determine if the relief of chest pain by NTG has diagnostic value. Design: Prospective observational cohort study. Setting: Academic Tertiary hospital with approximately 60,000 visits per year. Inclusion Criteria: Patients presenting to the emergency department (ED) with chest pain who received NTG from emergency personnel or an ED nurse. Follow-up was obtained by telephone contact at 2-4 weeks. Exclusion Criteria: Patients that presented with an EKG showing signs of an acute MI and patients that went to the cardiac catheterization lab emergently. Outcome Variables: Chest pain relief was defined as a decrease in chest pain by at least 50% within 10 minutes of receiving a dose of sublingual or spray NTG. Active CAD was defined as an elevated Troponin I level, coronary angiography with a stenosis ≥ 70%, or a positive provocative cardiac test (treadmill, cardiolyte, dobutamine stress, etc.) during the admission for chest pain. Results: Eighty-one patients were enrolled. NTG relieved chest pain in 65% of patients (53/81). Of the patients with active CAD as the likely cause of their chest pain, 72% (18/25) had chest pain relief with NTG. Chest pain relief occurred 63% (35/56) of the time in patients without CAD. Sensitivity was 72%. Specificity was 38%. The likelihood ratio was 1.1. Conclusions: In ED chest pain patients, relief of chest pain with NTG does not alter the pretest probability that the chest pain is secondary to active CAD. NTG should not be used to determine if chest pain is related to CAD.
Introduction“Doctor what is causing my Chest Pain (CP)?” This is a common problem in the Emergency Department (ED). The question of what is causing the CP can be a very difficult one. EKGs are used as the first diagnostic step. An EKG diagnostic of acute MI is an easy answer but what about a more common problem, the patient with a nondiagnostic EKG? If the EKG is nondiagnostic or normal does that mean the CP is non-cardiac?ObjectiveTo evaluate outcomes of ED CP patients with normal or non-specific EKG's.Design, Setting, and PatientsA prospective cohort study in an urban academic institution with 60,000 annual ED visits in which 269 patients with chest pain were enrolled.Setting, and PatientsA prospective cohort study in an urban academic institution with 60,000 annual ED visits in which 269 patients with chest pain were enrolled. Inclusion Criteria: ED CP patients with nondiagnostic EKGs were determined to be low risk because of a normal (n=121) or non-specific non-ischemic (n=148) EKGs. Non-specific non-ischemic EKG's were defined by the ED doctor caring for the patient toInclusion CriteriaED CP patients with nondiagnostic EKGs were determined to be low risk because of a normal (n=121) or non-specific non-ischemic (n=148) EKGs. Non-specific non-ischemic EKG's were defined by the ED doctor caring for the patient to not represent ischemia at the time of evaluation (s-t segment abnormalities were determined to be non-acute and non-ischemic). The initial EKG obtained in the ED was correlated to the hospital course, treatment, discharge diagnosis and phone call follow-up.Exclusion CriteriaPatients with EKG criteria consistent with acute myocardial infarction or active ischemia.Main Outcome MeasuresCP secondary to Coronary Artery Disease (CAD) was determined to be present based on cardiac angiogram results (stenosis ≥70%), + cardiac stress test, or +cardiac enzymes. CP not caused by CAD was determined based on a normal cardiac work-up associated with an unremarkable hospital discharge and a follow-up phone call at 2–;4weeks showing no cardiac event.ResultsCAD was determined to be the cause of CP in 12% of the patients with nondiagnostic EKGs. Nondiagnostic initial EKGs had a Sensitivity of 33% for CAD. The Negative Predictive Value of a nondiagnostic EKG was 69%. Even with a completely normal EKG (n=121) 5% of those patients with were diagnosed with CAD.ConclusionA normal or non-specific initial EKG does not reliably exclude CAD as the cause of CP.
IntroductionIt is commonly believed that chest pain relieved by taking nitroglycerin (NTG) is caused by active coronary artery disease (CAD). Is this medical myth or is this true?ObjectiveTo determine if the relief of chest pain by NTG has diagnostic value.DesignProspective observational cohort study.SettingAcademic Tertiary hospital with approximately 60,000 visits per year.Inclusion CriteriaPatients presenting to the emergency department (ED) with chest pain who received NTG from emergency personnel or an ED nurse. Follow-up was obtained by telephone contact at 2-4 weeks.Exclusion CriteriaPatients that presented with an EKG showing signs of an acute MI and patients that went to the cardiac catheterization lab emergently.Outcome VariablesChest pain relief was defined as a decrease in chest pain by at least 50% within 10 minutes of receiving a dose of sublingual or spray NTG. Active CAD was defined as an elevated Troponin I level, coronary angiography with a stenosis ≥ 70%, or a positive provocative cardiac test (treadmill, cardiolyte, dobutamine stress, etc.) during the admission for chest pain.ResultsEighty-one patients were enrolled. NTG relieved chest pain in 65% of patients (53/81). Of the patients with active CAD as the likely cause of their chest pain, 72% (18/25) had chest pain relief with NTG. Chest pain relief occurred 63% (35/56) of the time in patients without CAD. Sensitivity was 72%. Specificity was 38%. The likelihood ratio was 1.1.ConclusionsIn ED chest pain patients, relief of chest pain with NTG does not alter the pretest probability that the chest pain is secondary to active CAD. NTG should not be used to determine if chest pain is related to CAD.
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