PITFALLS IN THE EMERGENCY DEPARTMENT DIAGNOSIS OF ACUTE MYOCARDIAL INFARCTION

[Upper abdominal pain: a frequent and multifaceted leading symptom in primary care internal medicine]

Upper gastrointestinal symptoms are among the most common reasons for medical consultation and represent a challenge for general practitioners in the outpatient care setting. History taking, symptom evaluation and physical examination are the crucial steps toward establishing an initial working diagnosis. The subsequent abdominal ultrasound and laboratory analyses are essential tools for the differential diagnosis.

Variation in emergency department use of computed tomography for investigation of acute aortic dissection

INTRODUCTION

Acute aortic dissection (AAD) is a life-threatening condition making early diagnosis critical. Although 90% present with acute pain, the myriad of associated symptoms can make diagnosis a challenge. Our objective was to assess how we are using computed tomography to rule out acute aortic dissection specifically rate of ordering, diagnostic yield, and variation in practice.

METHODS

We included consecutive adult patients presenting to two tertiary academic care emergency departments over one calendar year presenting with non-traumatic chest, back, abdominal, or flank pain. Primary outcome was rate of CT thorax/abdomen ordered to rule out AAD. Secondary outcome was variation in CT ordering, measured comparing number of CTs ordered per physician. Sample size of 12 per group was calculated based on an expected delta in mean CT ordered of 5 and a within group SD of 3.

RESULTS

Thirty-one thousand two hundred one patients presented with truncal pain during the study period, 22,729 were included (mean 47 years, SD 18.5 years, 56.2% female); prevalence of AAD (N = 4) was 0.02%. CT was ordered to rule out AAD in 175 (0.7%) patients (mean 62 years, SD 16.5, 50.6% female). Significant variation between physicians ordering was found, with individual physicians ordering varying from 0.6 to 12%.

CONCLUSIONS

Current rate of imaging for acute aortic dissection is low and potentially inefficient, with a large variation in practice. These findings suggest potential for more standardized and efficient use of CT for the diagnosis of acute aortic dissection.

Presenting complaint among patients with myocardial infarction who present to an urban, public hospital emergency department

STUDY OBJECTIVE

We determine the frequency of patients presenting without a primary complaint of chest pain who are admitted with acute myocardial infarction (AMI) and identify factors associated with an increased risk of a presentation without chest pain.

METHODS

This was a retrospective, cross-sectional study over a 5-year period (July 1, 1993, to June 30, 1998) of patients presenting to a large urban, public hospital emergency department who were admitted and determined to have an AMI based on International Classification of Diseases, 9th Revision, coding and chart review. Main outcome measures were prevalence of presentation without chest pain and prevalence of other predefined presentations (ie, shortness of breath, cardiac arrest, abdominal pain, dizziness/weakness/syncope) as determined by the primary chief complaint entered on arrival at the ED. We calculated univariate relative risks and multivariate odds ratios (ORs) for presentation without chest pain in women, nonwhite ethnic groups, and older age groups.

RESULTS

Of the 721 cases of diagnosed AMI, 53% (380; 95% confidence interval [CI] 49% to 56%) of patients presented with chest pain. The frequency of other complaints were shortness of breath, 17% (121); cardiac arrest, 7% (50); dizziness/weakness/syncope, 4% (32); abdominal pain, 2% (14); and other, 17% (124). The risk of a presentation without chest pain in a patient with AMI increased with age. The characteristic with the highest risk for a presentation without chest pain in patients with AMI was age older than 84 years old (multivariate OR 5.76; 95% CI 3.06 to 10.83). Women were more likely than men to present without chest pain (multivariate OR 1.59; 95% CI 1.11 to 2.28).

CONCLUSION

Our results demonstrate that patients with AMI commonly present to the ED without a primary initial complaint of chest pain and that the frequency of initial presentations without chest pain in our urban, public hospital is as high or higher than that reported in the general ED population. Heightened awareness of atypical presentations may affect assessment of patients with AMI and provide further focus for research into presentations of acute coronary syndrome other than chest pain.