Efficacy of a diagnostic strategy for patients with chest pain and no ST-segment elevation in the emergency room

Abstract

Purpose -To evaluate the efficacy of a systematic model of care for patients with chest pain and no ST segment elevation in the emergency room. Methods -From 1003 patients submitted to an algorithm diagnostic investigation by probability of acute ischemic syndrome. We analyzed 600 ones with no elevation of ST segment, then enrolled to diagnostic routes of median (route 2) and low probability (route 3) to ischemic syndrome. Results - Efficacy of a Diagnostic Strategy for Patients with Chest Pain and No ST-Segment Elevation in the Emergency Room Original ArticleThe diagnostic management of patients arriving at the emergency room with chest pain is one of the great challenges of medical practice. This is due not only to the fact that several thoracic and nonthoracic diseases can be the cause of the symptom but also because some of these pathologies may have a very high mortality rate, as is the case with aortic dissection, pulmonary embolism and acute myocardial infarction. Therefore, emergency physicians usually are extremely cautious when they see these patients and try to identify and hospitalize those with high-risk diseases. Although aortic dissection and pulmonary embolism are infrequently seen in the emergency room (less than 1% of chest pain patients), acute myocardial infarction and unstable angina are more common (approximately 10% and 20%, respectively) [1][2][3][4] .Acute coronary insufficiency has the electrocardiogram as its diagnostic method of choice. However, several studies have demonstrated that this tool has low sensitivity for the diagnosis of this syndrome (about 50%) 5,6 . The present study tries to establish a rapid and accurate diagnostic strategy for patients seen in the emergency room with chest pain who do not have the typical electrocardiographic feature of acute myocardial infarction ( ST segment elevation ). MethodsPro-Cardiaco Hospital is a primary-and tertiary-care private institution for clinical and cardiologic patients located in the center of the city of Rio de Janeiro, Brazil. It has an active 9-bed emergency room and a cardiologist-staffed ambulance service for house-calls.To improve care of patients with chest pain and to make the diagnostic and therapeutic management uniform between attending physicians and house-staff, a diagnostic strategy was created according to the pretest probability of acute coronary insufficiency 6 . A systematic model was developed

Diretrizes (IIª Edição, 2007) da Sociedade Brasileira de Cardiologia sobre angina instável e infarto agudo do miocárdio sem supradesnível do segmento ST

“…visando um atendimento mais eficaz, mais rápido, mais seguro e menos dispendioso aos pacientes, principalmente àqueles que procuram hospitais gerais. Em 1996, o Hospital Pró-Cardíaco (RJ) iniciou o Projeto Dor Torácica executado pelo "staff" da Unidade de Emergência, com importante participação do Laboratório de Medicina do Exercício, que estabeleceu um regime de sobreaviso de seus médicos ergometristas, diariamente até 22 horas, incluindo sábados, domingos e feriados (28). O TE tem sido aplicado, principalmente, no paciente com dor atípica e eletrocardiograma não diagnóstico, após curva enzimática seriada normal.…”