Detection of myocardial ischemia/infarction in the emergency department patient with chest discomfort

Abstract

Detailed review of the literature for chest discomfort evaluation in the Emergency Department leaves the clinician without a precise guideline as to whom to admit or send home. It is clear that the seasoned physician's instinct (the sum total of the history, physician examination, and ancillary laboratory tests) is as good an indicator as existing statistical decision models. Current decision rules appear most helpful as teaching aids for physicians-in-training and for providing reassurance to seasoned physicians. Although ancillary tests such as echocardiography and rapid myoglobin analysis may play more important roles in the future, emergency physicians must now rely primarily upon their clinical impression to guide admission decisions. Vigorous attempts to minimize the admission of patients without ischemia to the CCU will increase the incidence of infarction patients released from the Emergency Department. The liberal use of intermediate care unit beds may represent one future disposition alternative. Nonetheless, each physician must establish his or her own threshold for admission. Several studies have found a 5 per cent unintentional release of infarction patients from the Emergency Department. Decreasing the admission threshold may lower this rate substantially. Patients with chest discomfort who are released from the Emergency Department require close followup. At urban teaching hospitals, where private physician referral is often limited, the institution may need to establish a clinic specifically for this purpose. Unrecognized myocardial ischemia is one rationale for close followup; however, the pursuit of alternative diagnoses including gastrointestinal and psychiatric (e.g., panic disorders) etiologies may minimize subsequent morbidity in the released population.