Pitfalls in Electrocardiographic Diagnosis of Acute Coronary Syndrome in Low-Risk Chest Pain

Serial Electrocardiograms-An Unsung Hero

This case report describes a patient in their 60s with diabetes and hypertension who presented to the emergency department with retrosternal chest pain.

Acid Reflux or Posterior Myocardial Infarction: One ECG Away From a Missed Diagnosis

Health care professionals and hospitals have made tremendous advances in detecting, diagnosing, and treating posterior myocardial infarction over many decades. Electrocardiogram (ECG) alone is used to make a timely diagnosis of ST-segment elevation myocardial infarction in the emergency department. The typical signs of myocardial infarction, left-sided chest discomfort with radiation to the jaw or left arm, rule out a wide range of patient presentations with ST-segment elevation myocardial infarction. This variation in clinical symptoms is exacerbated by the fact that most ECG monitors lack algorithms that account for posterior myocardial infarction interpretation. Therefore, health care practitioners must exercise caution when dismissing nondiagnostic and faint ECG abnormalities as normal or unimportant.

Comparison of self-reported EDACS versus physician-reported EDACS for the triage of chest pain patients in the emergency department

OBJECTIVES

Currently, there are no guidelines to help triage nurses identify high-risk emergency department chest pain patients. Patient self-reporting of Emergency Department Assessment of Chest Pain Score (EDACS) could facilitate more reliable triage compared to nursing gestalt, but this novel concept is untested. This study hypothesizes that because EDACS requires minimal clinical gestalt to derive, self-reported EDACS (S-EDACS) at triage is likely to correlate well with traditional physician-reported EDACS (P-EDACS) and have potential application as a triage tool.

METHODS

This single-center pilot prospective cohort study analyzed 60 patients who completed a self-reported questionnaire upon triage to determine their S-EDACS. This was matched against P-EDACS, derived from an identical questionnaire completed by the blinded treating physician. Secondary endpoint of major adverse cardiovascular events (MACE) within 30 days (all-cause mortality, myocardial infarction, coronary revascularization) was assessed by 2 blinded emergency physicians who independently reviewed the electronic medical records. S/P-EDACS also were benchmarked against nursing gestalt (based on triage to low/high-acuity areas) and emergency physician gestalt (disposition and admitting/discharge diagnoses).

RESULTS

There was perfect agreement between S/P-EDACS in this study (K = 1.00). Fifteen patients (25.0%) had minor discordances in their absolute S/P-EDACS that did not affect risk stratification. Of these, 11/15 (73.3%) had higher S-EDACS, suggesting S-EDACS is more likely to safely overcall MACE risk. S-EDACS outperformed nursing gestalt, triaging a greater proportion of patients (71.7% vs 35.0%) as low risk without compromising patient safety, and demonstrated similar accuracy as emergency physician gestalt.

CONCLUSION

S-EDACS strongly correlates with P-EDACS with perfect agreement and has potential to be used as a triage tool.

Value of early rest myocardial perfusion imaging with SPECT in patients with chest pain and non-diagnostic ECG in emergency department

Evaluation of atypical presentation of angina chest pain in emergency department is difficult. Hospitalization of this patient may impose additional costs and waste the time, early discharge may lead to miss the patients. The aim of this study was to determine volubility of Single Photon Emission Computed Tomography (SPECT) in management of patients admitted to emergency department with atypical manifestations of angina pain, un-diagnostic Electrocardiogram (ECG) and negative enzyme. Half of 100 patients admitted to emergency department with atypical chest pain and un-diagnostic ECG who were candidate for admission, underwent ECG gated resting SPECT. According to the results of SPECT, low risk patient discharged after negative stress SPECT. All discharged patients were followed up for major cardiac events (cardiac death, nonfatal myocardial infarction and repeat admission for congestive heart failure) for 12 months. According to rest SPECT Myocardial Perfusion Imaging (MPI), about 70% of patients in case group was low risk and 30% of them had moderate or high risk. Case group represented lower hospitalization rate and lower need for Coronary Artery Angiography (CAG) in comparison with control group. Mean cost in case group was significantly lower than control group (175.15$ vs. 391.33$, P < 0.001). In one year follow- up no cases of mortality or major cardiovascular events as cardiac infraction were found in discharged patients in case group. our study showed that rest SPECT fulfillment in admitted patients in emergency department was validated method for assessing patients' risk which avoids unnecessary hospitalizations and additional costs.