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Missed acute cardiac ischemia in the ED: limitations of diagnostic testing

      Abstract

      Correctly identifying and appropriately triaging patients who present to the ED with the broad range of symptoms suggestive of acute cardiac ischemia (ACI: unstable angina pectoris [UAP] and acute myocardial infarction [AMI]) remains one of the greatest challenges in EM. Although a number of diagnostic technologies have been described to aid in this triage process, each of these tests or technologies has limitations. We report a case series in which either the use of adjuncts with unknown performance or tests with known but not considered limitations could have contributed to the failure to appropriately triage and treat patients with ACI. Each case illustrates different aspects of this clinical challenge. One case illustrates the hazards of reliance on a single set of negative cardiac biomarkers. The limitations of a negative exercise electrocardiographic stress test (ETT) are illustrated in the second case. Finally, the limitations of a negative coronary angiogram, the “gold standard” test for symptomatic coronary artery disease, are discussed. We review the literature on technologies to aid in the evaluation of patients who present to the ED with symptoms suggestive of ACI.

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      References

        • Van Der Does E
        • Lubsen J
        • Pool J
        • et al.
        Acute coronary events in general practice.
        Heart Bull. 1976; 7: 91-98
        • Kinlen L
        Incidence and presentation of myocardial infarction in an English community.
        Br Heart J. 1973; 35: 681-686
        • Urestsky B
        • Farquahar D.S
        • Berezin A.F
        • Hood Jr, W.B
        Symptomatic myocardial infarction without chest pain.
        Am J Cardiol. 1977; 40: 498-503
        • Pope J.H
        • Ruthazer R
        • Beshansky J.R
        • Griffith J.L
        • Selker H.P
        The clinical presentation of patients with acute cardiac ischemia in the emergency department.
        J Thromb Thrombolysis. 1998; 6: 63-74
        • Georgeson S
        • Linzer M
        • Griffith J.L
        • Weld L
        • Selker H.P
        Acute cardiac ischemia in patients with syncope.
        J Gen Intern Med. 1992; 7: 379-386
        • Canto J.G
        • Shlipak M.G
        • Rogers W.J
        • et al.
        Prevalence, clinical characteristics, and mortality among patients with myocardial infarction presenting without chest pain.
        JAMA. 2000; 283: 3223-3229
        • Lee T.H
        • Rouan G.W
        • Weisberg M.C
        • et al.
        Clinical characteristics and natural history of patients with acute myocardial infarction sent home from the emergency room.
        Am J Cardiol. 1987; 60: 219-224
        • McCarthy B.D
        • Beshansky J.R
        • D’Agostino R.B
        • Selker H.P
        Missed diagnoses of acute myocardial infarction in the emergency department.
        Ann Emerg Med. 1993; 22: 579-582
        • Pope J.H
        • Aufderheide T.P
        • Ruthazer R
        • et al.
        Missed diagnoses of acute cardiac ischemia in the emergency department.
        N Engl J Med. 2000; 342: 1163-1170
        • Rusnak R.A
        • Stair T.O
        • Hansen K
        • Fastow J.S
        Litigation against the emergency physician.
        Ann Emerg Med. 1989; 18: 1029-1034
        • Sarasin F.P
        • Reymond J.M
        • Griffith J.L
        • et al.
        Impact of the Acute Cardiac Ischemia Time-Insensitive Predictive Instrument (ACI-TIPI) on the speed of triage decision making for emergency department patients presenting with chest pain.
        J Gen Intern Med. 1994; 9: 187-194
        • Selker H.P
        • Griffith J.L
        • D’Agostino R.B
        A time-insensitive predictive instrument for acute myocardial infarction mortality.
        Med Care. 1991; 29: 1196-1211
        • Karcz A
        • Holbrook J
        • Auerbach B.S
        • et al.
        Preventability of malpractice claims in emergency medicine.
        Ann Emerg Med. 1990; 19: 865-873
        • Karcz A
        • Korn R
        • Burke M.C
        • et al.
        Malpractice claims against emergency physicians in Massachusetts.
        Am J Emerg Med. 1996; 14: 341-345
        • Selker H.P
        • Zalenski R.J
        • Antman E.M
        • et al.
        An evaluation of technologies for identifying acute cardiac ischemia in the emergency department.
        Ann Emerg Med. 1997; 29 ([published erratum appears in Ann Emerg Med 1997;29:310]): 13-87
        • Ornato J.P
        • Selker H.P
        • Zalenski R.J
        Overview: diagnosing acute cardiac ischemia in the emergency department. A report from the National Heart Attack Alert Program.
        Ann Emerg Med. 2001; 37: 450-453
        • Lau J
        • Ioannidis J.P
        • Balk E.M
        • et al.
        Diagnosing acute cardiac ischemia in the emergency department.
        Ann Emerg Med. 2001; 37: 453-461
        • Sackett DL.H.B
        • Guyatt G.H
        • Tugwell P
        Clinical Epidemiology. Little, Brown and Co, Toronto1985
        • Braunwald E
        • Jones R.H
        • Mark D.B
        • et al.
        Diagnosing and managing unstable angina. Agency for Health Care Policy and Research.
        Circulation. 1994; 90: 613-622
        • Selker H.P
        • Beshansky J.R
        • Griffith J.L
        • et al.
        Use of the Acute Cardiac Ischemia Time-Insensitive Predictive Instrument (ACI-TIPI) to assist with triage of patients with chest pain or other symptoms suggestive of acute cardiac ischemia. A multicenter, controlled clinical trial.
        Ann Intern Med. 1998; 129: 845-855
        • Udelson J.E
        • Beshansky J.R
        • Ballin D.S
        • et al.
        Myocardial perfusion imaging for evaluation and triage of patients with suspected acute cardiac ischemia.
        JAMA. 2002; 288: 2693-2700
        • Balk E.M
        • Ioannidis J.P
        • Salem D.N
        • Chew P.W
        • Lau J
        Accuracy of biomarkers to diagnose acute cardiac ischemia in the emergency department.
        Ann Emerg Med. 2001; 37: 453-461
        • Limkakeng Jr, A
        • Gibler W.B
        • Pollack C
        • et al.
        Combination of Goldman risk and initial cardiac troponin I for emergency department chest pain patient risk stratification.
        Acad Emerg Med. 2001; 8: 696-702
      1. ACC/AHA 2002 Guideline Update for the Management of Patients With Unstable Angina and Non-ST-Segment Elevation Myocardial Infarction. vol 2002. 2002 (A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina))
        • Polanczyk C.A
        • Lee T.H
        • Cook E.F
        • et al.
        Cardiac troponin I as a predictor of major cardiac events in emergency department patients with acute chest pain.
        J Am Coll Cardiol. 1998; 32: 8-14
        • Hamm C.W
        • Goldmann B.U
        • Heeschen C
        • Kreymann G
        • Berger J
        • Meinertz T
        Emergency room triage of patients with acute chest pain by means of rapid testing for cardiac troponin T or troponin I.
        N Engl J Med. 1997; 337: 1648-1653
        • Hlatky M.A
        Evaluation of chest pain in the emergency department.
        N Engl J Med. 1997; 337 ([Editorial; Comment]): 1687-1689
        • Kontos M.C
        • Jesse R.L
        • Anderson F.P
        • Schmidt K.L
        • Ornato J.P
        • Tatum J.L
        Comparison of myocardial perfusion imaging and cardiac troponin I in patients admitted to the emergency department with chest pain.
        Circulation. 1999; 99: 2073-2078
        • Newby L.K
        • Christenson R.H
        • Ohman E.M
        • et al.
        • The GUSTO-IIa Investigators
        Value of serial troponin T measures for early and late risk stratification in patients with acute coronary syndromes.
        Circulation. 1998; 98: 1853-1859
        • Zimmerman J
        • Fromm R
        • Meyer D
        • et al.
        Diagnostic marker cooperative study for the diagnosis of myocardial infarction.
        Circulation. 1999; 99: 1671-1677
        • Olatidoye A.G
        • Wu A.H
        • Feng Y.J
        • Waters D
        Prognostic role of troponin T versus troponin I in unstable angina pectoris for cardiac events with meta-analysis comparing published studies.
        Am J Cardiol. 1998; 81: 1405-1410
        • Ebell M.H
        • Flewelling D
        • Flynn C.A
        A systematic review of troponin T and I for diagnosing acute myocardial infarction.
        J Fam Pract. 2000; 49: 550-556
        • Hill J
        • Timmis A
        Exercise tolerance testing.
        BMJ. 2002; 324: 1084-1087
        • Shaw L.J
        • Peterson E.D
        • Shaw L.K
        • et al.
        Use of a prognostic treadmill score in identifying diagnostic coronary disease subgroups.
        Circulation. 1998; 98: 1622-1630
        • Mark D.B
        Risk stratification in patients with chest pain.
        Prim Care. 2001; 28 (vii): 99-118
        • Pryor D.B
        • Shaw L
        • Harrell Jr, F.E
        • et al.
        Estimating the likelihood of severe coronary artery disease.
        Am J Med. 1991; 90: 553-562
        • Mark D.B
        • Shaw L
        • Harrell Jr, F.E
        • et al.
        Prognostic value of a treadmill exercise score in outpatients with suspected coronary artery disease.
        N Engl J Med. 1991; 325: 849-853
        • Mark D.B
        • Hlatky M.A
        • Harrell Jr, F.E
        • Lee K.L
        • Califf R.M
        • Pryor D.B
        Exercise treadmill score for predicting prognosis in coronary artery disease.
        Ann Intern Med. 1987; 106: 793-800
        • Weiner D
        • Ryan T
        • McCabe C
        • et al.
        Exercise stress testing. Correlations among history of angina, ST-segment response and prevalence of coronary-artery disease in the Coronary Artery Aurgery Study (CASS).
        N Engl J Med. 1979; 301: 230-235
        • Braunwald E
        Unstable angina. A classification.
        Circulation. 1989; 80: 410-414
        • Braunwald E
        • Antman E.M
        • Beasley J.W
        • et al.
        ACC/AHA guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction—2002: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Unstable Angina).
        Circulation. 2002; 106: 1893-1900
        • Mansourati J
        • Da Costa A
        • Munier S
        • et al.
        Prevalence of factor V Leiden in patients with myocardial infarction and normal coronary angiography.
        Thromb Haemost. 2000; 83: 822-825
        • Gehani A.A
        • al-Mulla A.W
        • Chaikhouni A
        • et al.
        Myocardial infarction with normal coronary angiography compared with severe coronary artery disease without myocardial infarction.
        J Cardiovasc Risk. 2001; 8: 1-8
        • Zir L.M
        • Miller S.W
        • Dinsmore R.E
        • Gilbert J.P
        • Harthorne J.W
        Interobserver variability in coronary angiography.
        Circulation. 1976; 53: 627-632
        • Udelson J.E
        • Beshansky J.R
        • Ballin D.S
        • et al.
        Myocardial perfusion imaging for evaluation and triage of patients with suspected acute cardiac ischemia.
        JAMA. 2002; 288: 2693-2700