Emergency management of cardiac chest pain: a review

Abstract

Chest pain accounts for 2%-4% of all new attendances at emergency departments (ED) in the United Kingdom.1 2 Chest pain can be the presenting complaint in a myriad of disorders ranging from life threats such as acute myocardial infarction (AMI) to mild self limiting disorders such as muscle strain. Possible cardac chest pain can be viewed as a continuum, ranging from total global AMI to simple short lived angina. Within this spectrum lie the acute coronary syndromes with critical cardiac ischaemia and minimal myocardial damage.Nationally over 129 000 deaths a year are attributable to ischaemic heart disease.3 AMI case mortality is currently 45% with over 70% of these dying before they reach medical care. 4 One in eight patients with unstable angina will infarct within two weeks without appropriate treatment. In the UK around 30% of patients with chest pain are admitted and 70% discharged from the ED 1 while in the United States 60% are admitted and 40% discharged. 4 Despite such high admission rates 3%-4% of AMI are inadvertently discharged from US EDs. In the UK significantly fewer patients are admitted; while the number of missed AMIs is unknown, recent evidence suggests that some 6% of patients discharged from EDs may have prognostically significant myocardial damage.

Missed diagnoses of acute myocardial infarction in the emergency department: variation by patient and facility characteristics

“…The rapid pace and short duration of observation may make patients in EDs particularly vulnerable to diagnostic error. Missed diagnoses in the ED often result in additional acute care services along with repeated testing, delays in appropriate treatment, increased mortality [32,33], and more dollars recovered in malpractice suits than any other medical error [34][35][36][37].…”

Effects of prolonged strenuous exercise (marathon running) on biochemical and haematological markers used in the investigation of patients in the emergency department

“…Many emergency departments and chest pain assessment units use measurement of these variables to rule out or rule in myocardial infarction. 1 In patients with suspected thromboembolic disease in the form of pulmonary embolism or deep vein thrombosis, clinical risk stratification occurs in conjunction with investigation. Many protocols for the investigation and treatment of patients with possible deep vein thrombosis or pulmonary embolism include measurement of D-dimers as part of the investigative process.…”

Echocardiography for chest pain in the emergency department

“…The ST segments on the electrocardiogram may be normal in 50% of patients with an acute coronary syndrome (6), while the levels of cardiac enzymes only rise after a minimum of 4 h or, in the case of troponin T, after 10 h. Either hospital admission or an extended stay in the emergency department may be necessary to avoid false negative results (7).…”