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Do patients' coronary risk factor reports predict acute cardiac ischemia in the emergency department? A multicenter
R L Jayes1, J R Beshansky, R B D'Agostino
1Department of Medicine, New England Medical Center, Boston, MA 02111.
Insights
Classical coronary risk factors have minimal impact on acute cardiac ischemia risk in women. In men, only diabetes and family history of myocardial infarction slightly increase risk, far less than chest pain or ECG findings.
Area of Science:
- Cardiology
- Emergency Medicine
- Clinical Risk Assessment
Background:
- Acute cardiac ischemia is a critical diagnosis in emergency departments.
- Classical coronary risk factors are traditionally considered significant predictors of cardiac events.
- The incremental predictive value of these factors in the acute setting requires further elucidation.
Purpose of the Study:
- To assess if classical coronary risk factors increase acute cardiac ischemia likelihood beyond clinical presentation and electrocardiogram (ECG).
- To quantify the relative risk associated with specific coronary risk factors in patients presenting with ischemic symptoms.
Main Methods:
- Prospective data collection of clinical information and coronary risk factors from 1743 patients without obvious coronary disease.
- Logistic regression analysis was employed to determine the relative risk of each factor for acute ischemia.
- Patients were selected from a larger cohort presenting to emergency departments with symptoms suggestive of acute ischemia.
Main Results:
- In women, classical risk factors did not significantly increase the risk of acute ischemia.
- In men, only diabetes and family history of myocardial infarction showed a significant increase in risk (relative risks 2.4 and 2.1, respectively).
- These risks were substantially lower than those associated with chest pain (12.1) and abnormal ECG findings (ST segment 8.7, T wave 5.3).
Conclusions:
- Classical coronary risk factors provide minimal additional risk information for acute cardiac ischemia in the emergency department setting.
- Presenting symptoms and ECG findings are far more critical indicators of acute ischemia than traditional risk factors.
- Risk stratification for acute cardiac ischemia should prioritize immediate clinical and electrocardiographic data over historical risk factors.
Abstract:
The objective of the present study was to determine whether the presence of the classical coronary risk factors increases the likelihood of acute cardiac ischemia beyond that expected from clinical presentation and electrocardiogram. Clinical data and reports of classical coronary risk factors were collected prospectively from 1743 patients without clinically obvious coronary disease. Patients were selected from 5773 emergency department patients at 6 hospitals who presented with symptoms suggesting acute ischemia. We used logistic regression to determine the relative risk of each risk factor report for acute ischemia. In women, the presence of classical risk factor reports does not increase the risk of acute ischemia. In men, only diabetes and family history of myocardial infarction significantly increase the risk (p less than 0.05). The relative risks are 2.4 and 2.1, respectively, and are small compared to those conferred by chest pain (12.1), an abnormal ST segment (8.7), or an abnormal T wave (5.3). For a patient presenting to the emergency department, the classical coronary risk factors convey minimal risk for acute cardiac ischemia, especially when compared to the overwhelming importance of the chief complaint and the ECG.