Limitations of chest pain follow-up from an urban teaching hospital emergency department.

Close outpatient follow-up of chest pain patients released from the emergency department (ED) has been suggested as an important means of detecting atypical presentations of cardiac ischemia. Urban teaching hospital patient populations often have limited private physician follow-up options and rely upon standard teaching hospital clinic systems. We analyzed the follow-up of 318 patients 30 or more years of age with nontraumatic chest pain released from the ED of a large urban teaching hospital. The planned disposition of the released patients was as follows: a medical clinic (136), another clinic or a private physician (76), or ED "as needed" (98); in addition, some patients left against medical advice (AMA) (8). The medical clinics received only 38% (51/136) of planned referrals. No subsequent record could be found for 13% (17/136) of referred patients. Only 17% (23/136) of referred patients were reevaluated within seven days. Two of the patients referred to medical clinics were admitted to the hospital within 24 hours for unstable angina and another was admitted from a medical clinic 16 days after ED evaluation with an acute myocardial infarction. Of patients with ED follow-up "as needed," one patient required admission for unstable angina 27 days after ED evaluation. Of the patients who left AMA, only two were reevaluated within 30 days. These findings suggest that specific measures to enhance follow-up must be instituted at urban teaching hospitals if chest pain patients are to be closely followed after ED release.

A chest pain clinic to improve the follow-up of patients released from an urban university teaching hospital emergency department.

During a 12-month period, 1,045 of 1,554 patients (67%) over age 30 seen in an urban teaching hospital emergency department with acute chest pain were released based on the clinical judgment of the examining physician. Patients who were released were offered follow-up within 24 to 72 hours in a hospital-based chest pain clinic. Of these 1,045 patients, 772 (74%) returned or were contacted by phone, and 29 were directly admitted; 14 had unstable angina, and eight had new myocardial infarctions. Because of its positive impact on the quality of care at an acceptable cost, the Chest Pain Clinic, which was originally instituted as part of a research protocol, has now become part of the routine spectrum of care provided at the University of Cincinnati Medical Center.

Clinical characteristics and natural history of patients with acute myocardial infarction sent home from the emergency room.

In a prospective multicenter investigation of emergency room patients with acute chest pain, physicians admitted 96% of patients with acute myocardial infarction (AMI) and discharged 4%. Of 35 patients who were sent home with AMI, only 11 (31%) returned to the same hospital because of persistent symptoms. Compared with a control group of 105 randomly selected patients with AMI who were admitted from the emergency room, patients in whom AMI was missed were significantly younger, had less typical symptoms and were less likely to to have had prior AMI or angina or to have electrocardiographic evidence of ischemia or infarction not known to be old. Despite the less typical presentations of patients in whom AMI was missed, after controlling for age and sex, the short-term mortality rate was significantly higher among patients in whom AMI was missed but in whom it was detected through our follow-up procedures than in admitted AMI patients. As determined by independent reviewers, 49% of the missed AMIs could have been diagnosed through improved electrocardiographic reading skills or by admission of patients with recognized ischemic pain at rest or ischemic electrocardiographic changes not known to be old.

Use of cardiac enzymes identifies patients with acute myocardial infarction otherwise unrecognized in the emergency department.

Recognition of an acute myocardial infarction in the patient with chest pain is a frequent challenge to the clinician. Previous studies suggest that cardiac enzymes are of limited value in identifying patients with acute MI in the emergency department. Such studies have not evaluated the use of cardiac enzyme tests to complement decision making in the population of patients clinically designated for ED release. We studied 773 ED visits by patients age greater than or equal to 30 years presenting with chest pain unexplained by thoracic trauma or radiographic abnormalities. Cardiac enzyme levels were not available to the clinicians at the time of the initial visit and disposition of these patients was determined solely by clinical and ECG evaluation. Of the 291 admitted patients, 46 had an MI; 22 of the MI patients had a normal creatine kinase (CK) level. Of the 482 patients released from the ED, 181 patients had an elevated CK level. Among the released patients were five patients with MI. Four released MI patients had a CK level greater than or equal to 200 IU/L and three had an elevated CK-MB fraction (greater than or equal to 12 IU/L). In the population of patients scheduled for release, an elevated CK-MB had sensitivity, specificity, and positive predictive value for MI of 60%, 100%, and 60%, respectively. Although cardiac enzymes cannot be used in isolation to make admission decisions, selective use of CK-MB for final screening of patients otherwise scheduled for ED release may enhance the initial admission of patients with MI at risk for unintentional release.