The recognition of acute coronary ischemia in the outpatient setting
Zehra Jaffery1, Michael P Hudson, Sanjaya Khanal
1Department of Internal Medicine, Henry Ford Hospital, 2799 West Grand Boulevard, Detroit, MI 48202, USA. zjyaali@yahoo.com
Insights
Many patients visit outpatient providers before acute myocardial infarction (AMI). However, few show coronary ischemia symptoms, and these are often misidentified, highlighting diagnostic challenges in outpatient care.
Area of Science:
- Cardiology
- Internal Medicine
- Diagnostic Accuracy
Background:
- Missed diagnosis of acute myocardial infarction (AMI) is a known issue in emergency departments.
- Limited research exists on the accurate identification of coronary ischemia in outpatient settings.
Purpose of the Study:
- To investigate the frequency and accuracy of diagnosing coronary ischemia in the outpatient setting within 30 days preceding an acute myocardial infarction.
Main Methods:
- Retrospective observational study of patients hospitalized with AMI.
- Review of outpatient encounters within 30 days prior to AMI by two independent cardiologists.
- Classification of patient presentations as acute coronary ischemia, stable angina, or neither.
Main Results:
- Of 68 patients with outpatient encounters before AMI, only 10% presented with acute coronary ischemia symptoms.
- Of those with ischemic symptoms, 2 out of 7 were misidentified.
- A majority of patients (83%) had no symptoms suggestive of coronary ischemia during outpatient visits.
Conclusions:
- Most patients experiencing AMI have outpatient visits in the preceding month.
- Coronary ischemia symptoms are infrequent in the outpatient setting and are not consistently identified correctly.
Background:
The missed diagnosis of acute myocardial infarction has been studied in the Emergency Department, but few studies have investigated how often coronary ischemia is correctly identified in the outpatient setting.
Methods:
This was a single center retrospective observational study of patients with Health Alliance Plan medical insurance hospitalized at a US tertiary center with acute myocardial infarction in 2004. Outpatient encounters in the 30 days preceding acute myocardial infarction were reviewed by two independent cardiologists for presenting symptoms and diagnostic decision-making in order to classify patient presentations as acute coronary ischemia, stable angina or neither.
Results:
There were 331 patients with acute myocardial infarction, including 190 (57%) with a primary diagnosis of AMI and evaluated by a physician in the preceding 30 days. This group included 68 patients with 95 documented outpatient encounters by a primary care physician, cardiologist, or other internal medicine specialist which formed the final study population. Mean interval between these encounters and AMI was 17 +/- 11 days. Of these patients, 7 (10%) had symptoms of acute coronary ischemia, 5 (7%) had stable angina symptoms, and 56 (83%) had no symptoms of coronary ischemia at their outpatient encounters. Of the 7 patients with acute coronary ischemic symptoms, 5 were correctly identified and 2 were misidentified.
Conclusion:
A majority of patients with subsequent AMI visit an outpatient provider in the month preceding AMI. However, few present with symptoms of coronary ischemia in the outpatient setting (10%) and these symptoms are not always identified as such.
More Related Videos
Related Concept Videos
01:30Acute Coronary Syndrome III: Diagnostic Studies
01:28Acute Coronary Syndrome IV: Interprofessional Care
01:30Acute Coronary Syndrome I: Introduction
01:19Acute Coronary Syndrome II: Pathophysiology and Clinical Manifestations
01:26Acute Coronary Syndrome V: Nursing Management
01:27Coronary Artery Disease V: Interprofessional Care