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Evaluating chest pain in the emergency department
1Ambulatory Care Service, Veterans Affairs Medical Center, Albuquerque, NM 87108.
Insights
Diagnosing chest pain in the emergency department is challenging. New methods improve detection of myocardial infarction (heart attack), aiding emergency physicians in risk assessment and triage.
Area of Science:
- Emergency Medicine
- Cardiology
- Diagnostic Imaging
Background:
- Chest pain presents a significant diagnostic challenge in emergency departments, with missed myocardial infarction (MI) leading to substantial malpractice claims.
- Atypical presentations of MI are common and associated with poorer prognoses, complicating accurate and timely diagnosis.
- Physician inexperience and failure to consider MI in the differential diagnosis contribute to diagnostic errors.
Purpose of the Study:
- To review the diagnostic challenges of chest pain in the emergency department.
- To highlight advancements in diagnosing myocardial infarction.
- To emphasize the importance of considering differential diagnoses for chest pain.
Main Methods:
- Review of clinical manifestations of myocardial infarction.
- Discussion of new immunochemical methods for creatine kinase-MB (CK-MB) assessment.
- Evaluation of the prognostic value of initial electrocardiogram (ECG) findings.
Main Results:
- Atypical chest pain symptoms (sharp, positional, pleuritic, reproducible by palpation) suggest a lower probability of acute ischemic heart disease.
- Improved sensitivity of CK-MB assays and serial sampling strategies enhance MI detection.
- Initial ECG findings provide valuable prognostic information for risk stratification.
Conclusions:
- Emergency physicians must be adept at recognizing diverse MI presentations and utilizing advanced diagnostic tools.
- Newer diagnostic methods improve the accuracy and speed of MI diagnosis in emergency settings.
- Effective risk assessment and triage are crucial for managing patients with chest pain, considering both MI and other potential conditions.
Abstract:
Chest pain is one of the most difficult diagnostic problems for physicians working in an emergency department. In this setting, more malpractice dollars are awarded for missed myocardial infarction than for any other physician error. This problem usually occurs when the patient has atypical symptoms, the physician is inexperienced, or the diagnosis is not considered. The clinical manifestations of myocardial infarction vary greatly, and patients with "atypical" presentations have a poorer prognosis than those with classic symptoms. Although no feature of a patient's history excludes infarction with certainty, pain that is sharp, positional, pleuritic, or reproduced by palpation indicates a lower probability of acute ischemic heart disease. New immunochemical methods and serial sampling strategies have increased the sensitivity of creatine kinase-MB as an indicator for the disorder. Recent investigations have also established the prognostic value of the initial electrocardiogram. These methods allow emergency physicians to assess the risk of complications and to perform triage when there is a shortage of beds in the coronary care unit. Emergency physicians must also consider other diseases for which coronary care might be beneficial.