ABSTRACT
OBJECTIVE: To assess safety, feasibility, and the results of early exercise testing in patients with chest pain admitted to the emergency room of the chest pain unit, in whom acute myocardial infarction and high-risk unstable angina had been ruled out. METHODS: A study including 1060 consecutive patients with chest pain admitted to the emergency room of the chest pain unit was carried out. Of them, 677 (64 percent) patients were eligible for exercise testing, but only 268 (40 percent) underwent the test. RESULTS: The mean age of the patients studied was 51.7±12.1 years, and 188 (70 percent) were males. Twenty-eight (10 percent) patients had a previous history of coronary artery disease, 244 (91 percent) had a normal or unspecific electrocardiogram, and 150 (56 percent) underwent exercise testing within a 12-hour interval. The results of the exercise test in the latter group were as follows: 34 (13 percent) were positive, 191 (71 percent) were negative, and 43 (16 percent) were inconclusive. In the group of patients with a positive exercise test, 21 (62 percent) underwent coronary angiography, 11 underwent angioplasty, and 2 underwent myocardial revascularization. In a univariate analysis, type A/B chest pain (definitely/probably anginal) (p<0.0001), previous coronary artery disease (p<0.0001), and route 2 (patients at higher risk) correlated with a positive or inconclusive test (p<0.0001). CONCLUSION: In patients with chest pain and in whom acute myocardial infarction and high-risk unstable angina had been ruled out, the exercise test proved to be feasible, safe, and well tolerated
Subject(s)
Humans , Male , Female , Middle Aged , Chest Pain , Emergency Service, Hospital , Exercise Test , Cohort Studies , Equipment Safety , Feasibility Studies , Prospective Studies , Treatment OutcomeABSTRACT
PURPOSE: To evaluate the efficacy of a systematic model of care for patients with chest pain and no ST segment elevation in the emergency room. METHODS: From 1003 patients submitted to an algorithm diagnostic investigation by probability of acute ischemic syndrome. We analyzed 600 ones with no elevation of ST segment, then enrolled to diagnostic routes of median (route 2) and low probability (route 3) to ischemic syndrome. RESULTS: In route 2 we found 17 per cent acute myocardial infarction and 43 per cent unstable angina, whereas in route 3 the rates were 2 per cent and 7 per cent, respectively. Patients with normal/non--specific ECG had 6 per cent probability of AMI whereas in those with negative first CKMB it was 7 per cent; the association of the 2 data only reduced it to 4 per cent. In patients in route 2 the diagnosis of AMI could only be ruled out with serial CKMB measurement up to 9 hours, while in route 3 it could be done in up to 3 hours. Thus, sensitivity and negative predictive value of admission CKMB for AMI were 52 per cent and 93 per cent, respectively. About one-half of patients with unstable angina did not disclose objective ischemic changes on admission. CONCLUSION: The use of a systematic model of care in patients with chest pain offers the opportunity of hindering inappropriate release of patients with ACI and reduces unnecessary admissions. However some patients even with normal ECG should not be released based on a negative first CKMB. Serial measurement of CKMB up to 9 hours is necessary in patients with medium probability of AMI.
Subject(s)
Humans , Angina, Unstable/diagnosis , Chest Pain/etiology , Emergency Medical Services , Myocardial Infarction/diagnosis , Chest Pain/diagnosis , Predictive Value of Tests , Prospective Studies , Sensitivity and SpecificityABSTRACT
OBJECTIVE: To evaluate the efficiency of a systematic diagnostic approach in patients with chest pain in the emergency room in relation to the diagnosis of acute coronary syndrome (ACS) and the rate of hospitalization in high-cost units. METHODS: One thousand and three consecutive patients with chest pain were screened according to a pre-established process of diagnostic investigation based on the pre-test probability of ACS determinate by chest pain type and ECG changes. RESULTS: Of the 1003 patients, 224 were immediately discharged home because of no suspicion of ACS (route 5) and 119 were immediately transferred to the coronary care united because of ST elevation or left bundle-branch block (LBBB) (route 1) (74 per cent of these had a final diagnosis of acute myocardial infarction [AMI]). Of the 660 patients that remained in the emergency room under observation, 77 (12 per cent) had AMI without ST segment elevation and 202 (31 per cent) had unstable angina (UA). In route 2 (high probability of ACS) 17 per cent of patients had AMI and 43 per cent had UA, whereas in route 3 (low probability) 2 per cent had AMI and 7 per cent had UA. The admission ECG has been confirmed as a poor sensitivity test for the diagnosis of AMI ( 49 per cent), with a positive predictive value considered only satisfactory (79 per cent). CONCLUSION : A systematic diagnostic strategy, as used in this study, is essential in managing patients with chest pain in the emergency room in order to obtain high diagnostic accuracy, lower cost, and optimization of the use of coronary care unit beds.
Subject(s)
Humans , Male , Female , Middle Aged , Cardiac Output, Low/diagnosis , Chest Pain/diagnosis , Emergency Medical Services , Angina, Unstable/diagnosis , Costs and Cost Analysis , Echocardiography , Electrocardiography , Length of Stay , Myocardial Infarction/diagnosis , Predictive Value of Tests , Sensitivity and SpecificitySubject(s)
Humans , Ergometry , Emergency Service, Hospital , Angina, Unstable/diagnosis , Angina, Unstable/therapy , Chest PainABSTRACT
PURPOSE: To identify in the elderly adaptations imposed by exercise in both sexes. METHODS: 1528 stress tests were performed on subjects divided in: group I (GI) (90) between 65 to 75 years old, and group II (GII) more than 75 years old. Protocols applied were Bruce (72), and modified Naughton (28). Clinical, hemodynamic and electrocardiographic variables were estimated as recommended by the World Health Organization, and the metabolic variables in the adapted Naughton protocols by the American College of Sports Medicine standards. RESULTS: Analysis of GI and GII, respectively disclosed: 1) stress electrocardiogram (ECG): normal, 36 and 35; ST depression, 20 and 22; ST elevation, 6 and 1; ventricular ectopic beats, 11 and 14; supra ventricular ectopic beats, 5 and 6; 2) metabolic and hemodynamic variables: the double-product: 26636 (+/-1539) and 23133 (+/-3218) mmHg X bpm (p < 0.0001). Maximum oxygen uptake measured in METS: GI, men, 7.7 (+/-1.9), women 5.4 (+/-0.8) (p < 0.0001); GII, NS, curve of systolic blood pressure: GI, men, 8.4 +/- (0.5), women, 10.6 (+/-1.8) mmHg/Met (p = 0.03); GII- NS. Difference of diastolic blood pressure and heart rate during exercise were similar between the two groups; 3) chest pain was the main clinical variable. CONCLUSION: The more frequent indication for stress testing to evaluate chest pain in GI, did not correspond to a predominance of this symptom in this group, during exercise; in GI, in contrast to what is seen in the young, the curve of systolic blood pressure was greater in women; despite the greater prevalence of coronary artery disease in aged subjects, it was not observed significative differences between the two groups, to ischaemic ST depression.