Early prediction of acute myocardial infarction from clinical history, examination and electrocardiogram in the emergency room

Karlson, Björn W.; Herlitz, Johan; Wiklund, O.; Richter, Arina; Hjalmarson, Åke

doi:10.1016/0002-9149(91)90739-8

Cited by 140 publications

(77 citation statements)

References 20 publications

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“…Previous studies have demonstrated that clinical gestalt and ECG alone are insufficient to identify a patient population safe for discharge from the ED. [10][11][12][13][14][15]17,18,20,21,23,31,32 Our study likewise found a significant event rate even in the lowest risk group. Yet the need to avoid sending any patient with ACS home from the ED has led to increasing hospital admissions and use of vast resources on many patients who ultimately do not have a diagnosis of ACS.…”

Section: Discussionsupporting

confidence: 77%

“…Yet the need to avoid sending any patient with ACS home from the ED has led to increasing hospital admissions and use of vast resources on many patients who ultimately do not have a diagnosis of ACS. 12,33 This challenge has led to the development of new objective tools, including new technologies (15 lead ECGs, 34,35 body surface mapping, [36][37][38][39][40] neural networks, 41,42 serum biomarkers, 25,27,28,30,[43][44][45][46][47][48] stress testing, 5,33,49,50 computed tomography [CT] coronary angiography 51,52 ) and risk stratification tools 11,31,53-55 to aid physicians in decision-making. Although promising, none of these are as yet widely accepted as a means to identify patients who can be safely discharged from the ED.…”

Section: Discussionmentioning

confidence: 99%

“…5,6 However, research has shown that the information most commonly available at the time of presentation, namely patient history, physical exam, electrocardiogram (ECG), and initial serum biomarkers, are insufficient by themselves to rule out the entire spectrum of ACS. 5,[7][8][9][10][11][12][13][14][15][16][17][18][19][20] Because the ECG and biomarkers are often initially normal, the physician's estimate of a patient's risk for ACS is usually the critical determinant of patient disposition. The desire to avoid missing ACS has increased rates of ACS evaluation so much that some chest pain centers now report that 98% of their evaluations are negative.…”

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confidence: 99%

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Emergency Physician High Pretest Probability for Acute Coronary Syndrome Correlates with Adverse Cardiovascular Outcomes

Chandra

Lindsell

Diercks

et al. 2009

Academic Emergency Medicine

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Objectives: The value of unstructured physician estimate of risk for disease processes, other than acute coronary syndrome (ACS), has been demonstrated. The authors sought to evaluate the predictive value of unstructured physician estimate of risk for ACS in emergency department (ED) patients without obvious initial evidence of a cardiac event.Methods: This was a post hoc secondary analysis of the Internet Tracking Registry for Acute Coronary Syndromes (i*trACS), a prospectively collected multicenter data registry of patients over the age of 18 years presenting to the ED with symptoms of ACS between 1999 and 2001. In this registry, following patient history, physical exam, and electrocardiogram (ECG), the unstructured treating physician estimate of risk was recorded. A 30-day follow-up and a medical record review were used to determine rates of adverse cardiac events, death, myocardial infarction (MI), or revascularization procedure. The analysis included all patients with nondiagnostic ECG changes, normal initial biomarkers, and a non-MI initial impression from the registry and excluded those without complete data or who were lost to follow-up. Data were stratified by unstructured physician risk estimate: noncardiac, low risk, high risk, or unstable angina.Results: Of 15,608 unique patients in the registry, 10,145 met inclusion ⁄ exclusion criteria. Patients were defined as having unstable angina in 6.0% of cases; high risk, 23.5% of cases; low risk, 44.2%; and noncardiac, 26.3% of cases. Adverse cardiac event rates had an inverse relationship, decreasing from 22.0% (95% confidence interval [CI] = 18.8% to 25.6%) for unstable angina, 10.2% (95% CI = 9.0% to 11.5%) for those stratified as high risk, 2.2% (95% CI = 1.8% to 2.6%) for low risk, and to 1.8% (95% CI = 1.4% to 2.4%) for noncardiac. The relative risk (RR) of an adverse cardiac event for those with an initial label of unstable angina compared to those with a low-risk designation was 10.2 (95% CI = 8.0 to 13.0). The RR of an event for those with a high-risk initial impression compared to those with a low-risk initial impression was 4.7 (95% CI = 3.8 to 5.9). The risk of an event among those with a low-risk initial impression was the same as for those with a noncardiac initial impression (RR = 0.83, 95% CI = 0.6 to 1.2). Conclusions:In ED patients without obvious initial evidence of a cardiac event, unstructured emergency physician (EP) estimate of risk correlates with adverse cardiac outcomes.ACADEMIC EMERGENCY MEDICINE 2009; 16:740-748 ª

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Section: Discussionsupporting

confidence: 77%

Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

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Emergency Physician High Pretest Probability for Acute Coronary Syndrome Correlates with Adverse Cardiovascular Outcomes

Chandra

Lindsell

Diercks

et al. 2009

Academic Emergency Medicine

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“…2) However, chest pain related to AMI varies signifi cantly both in its intensity 3,4) and incidence. 5,6) In addition, the pain severity does not seem to be a good predictor of the outcome of myocardial infarction.…”

Section: )mentioning

confidence: 99%

Behavioral Changes Following Experimentally-Induced Acute Myocardial Infarction in Rats

et al. 2014

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SummaryRats with experimentally-induced acute myocardial infarction (AMI) have proven to be a clinically relevant model for visceral pain. As there are no behavioral data available on rats in the postinfarction period, we aimed to identify specifi c pain-related behavioral changes following AMI to increase the validity of the model. AMI was induced by left coronary artery ligation and pain-related behavior was analyzed using the open fi eld test (OFT) and elevated plus maze (EPM). Morphine was applied following AMI induction to differentiate pain-related changes from those related to nonspecifi c global changes in responsiveness. AMI was histologically confi rmed.Hypolocomotion was consistently evident in all behavioral tests for both the infarcted group and sham group. In the OFT, both AMI and sham rats exhibited less exploratory behavior and less activity. A similar pattern of behavior was observed in EPM, where both surgical groups showed fewer entries to the open arms and spent less time in the open arms. The sham group with an intact pericardium showed the same pattern of activity as control rats. The reduction in activity and rearing observed following AMI was successfully reversed following morphine injection. This effect was abolished after naloxone application allowing us to attribute observed changes specifi cally to pain.This study demonstrates that pain-related behavior in the acute postinfarction period is generally characterized by reduced mobility and explorative behavior. Our results showed that cardiac ischemia as a consequence of experimentally-induced infarction is a less important source of pain behavior than manipulation of the pericardium. (Int Heart J 2014; 55: 169-177) Key words: Pericardium, Postoperative pain, Behavior C hest pain is the primary and the most prominent symptom leading to the hospitalization of patients with the diagnosis of acute myocardial infarction (AMI). 1)These patients account for 20% of patients in medical emergency departments.2) However, chest pain related to AMI varies signifi cantly both in its intensity 3,4) and incidence. 5,6) In addition, the pain severity does not seem to be a good predictor of the outcome of myocardial infarction. 7)While the evaluation of pain in humans is predominantly based on conscious perception, in animals it relies mainly on behavioral output. 8) Defined by the International Association for the Study of Pain (IASP) as an unpleasant sensory and emotional experience, 9) pain cannot be determined in animals, so proxy indicators are typically used. In order to increase the translational value of their studies, pain researchers working with experimental animals have focused more on complex behavioral responses and operant measures.10,11) Visceral pain models, eg, models of cardiac ischemia, delineate well these challenges. Pain elicited in these models is vague, with no specifi c region to focus pain measurements on, so broader behavioral and cognitive analysis is necessary to detect potential changes.12)The most commonly used stimuli i...

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“…Initial evaluation, including a history and physical examination and 12-lead ECG, is conclusive in only a minority of patients. 1,2 The use of cardiac markers has become standard to further risk-stratify such patients. Often this is done in a chest pain unit (CPU), following protocols for marker testing over 6 to 12 hours.…”

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confidence: 99%

Bedside Multimarker Testing for Risk Stratification in Chest Pain Units

2001

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Background-Earlier, rapid evaluation in chest pain units may make patient care more efficient. A multimarker strategy (MMS) testing for several markers of myocardial necrosis with different time-to-positivity profiles also may offer clinical advantages. Methods and Results-We prospectively compared bedside quantitative multimarker testing versus local laboratory results (LL) in 1005 patients in 6 chest pain units. Myoglobin, creatine kinase-MB, and troponin I were measured at 0, 3, 6, 9 to 12, and 16 to 24 hours after admission. Two MMS were defined: MMS-1 (all 3 markers) and MMS-2 (creatine kinase-MB and troponin I only).

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Early prediction of acute myocardial infarction from clinical history, examination and electrocardiogram in the emergency room

Cited by 140 publications

References 20 publications

Emergency Physician High Pretest Probability for Acute Coronary Syndrome Correlates with Adverse Cardiovascular Outcomes

Emergency Physician High Pretest Probability for Acute Coronary Syndrome Correlates with Adverse Cardiovascular Outcomes

Behavioral Changes Following Experimentally-Induced Acute Myocardial Infarction in Rats

Bedside Multimarker Testing for Risk Stratification in Chest Pain Units

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