QUALITY GRAND ROUNDS Series Editors: Robert M. Wachter, MD; Kaveh G.

Shojania, MD; Sanjay Saint, MD, MPH; Amy J. Markowitz, JD; and Mark Smith, MD, MBA

Improving Patient Care

Triage of Patients with Acute Chest Pain and Possible Cardiac Ischemia: The Elusive Search for Diagnostic Perfection
Lee Goldman, MD, and Ajay J. Kirtane, MD*

Few diagnostic decisions in medicine have been more heavily researched than the approach to the patient with acute chest pain. Despite the advances in both diagnosing and treating patients presenting with this symptom, cases of missed myocardial infarctions still cause substantial morbidity and mortality. This article examines a case in which a patient was sent home from the emergency department after presenting with chest pain and was subsequently found to have a myocardial infarction. In the context of the case, the article discusses clinical decision making about

the diagnosis and triage of patients presenting with acute chest pain or with symptoms consistent with possible cardiac ischemia. A standardized approach to addressing the management of these patients is essential, given the adverse consequences of missing a life-threatening condition.
Ann Intern Med. 2003;139:987-995. www.annals.org For author affiliations, see end of text. For a list of questions and answers from the Quality Grand Rounds conference, see the Appendix, available at www.annals.org.

Quality Grand Rounds is a series of articles and companion conferences designed to explore a range of quality issues and medical errors. Presenting actual cases drawn from institutions around the United States, the articles integrate traditional medical case histories with results of root-cause analyses and, where appropriate, anonymous interviews with the involved patients, physicians, nurses, and risk managers. Cases do not come from the discussants home institutions.

SUMMARY

OF THE

CASE

Mrs. T., a 68-year-old woman with many cardiac risk factors and a history of myocardial infarction (MI), presented with atypical symptoms but a changed electrocardiogram (ECG). These ECG changes were not appreciated by Dr. M., the emergency department physician, and Mrs. T. was mistakenly sent home with what proved to be an acute MI. Dr. M. was interviewed by a Quality Grand Rounds editor on 21 March 2002.

THE CASE
Twelve hours before presenting to the emergency department, Mrs. T. called the hospitals telephone triage nurse and reported dull, midsternal pain relieved after a bowel movement. After probing for associated symptoms, the nurse reassured the patient and told her to call back if she experienced any further discomfort. Several hours later, when the pain recurred, Mrs. T. called again. When asked whether she had sublingual nitroglycerin on hand, Mrs. T. conrmed that she had a bottle of nitroglycerin pills but that the expiration date had passed. She was told to take the nitroglycerin if the pain recurred and was given an appointment for 2 days later (at which time she was instructed to exchange her expired bottle for a new one). She was advised to call 911 if the pain recurred

and was associated with nausea, diaphoresis, or dyspnea. Because of continued pain, the patient came into the emergency department of a large urban hospital 4 hours later (at approximately 2:00 a.m.) with a chief symptom of chest pain. The patient had a history of inferior-wall MI, hypertension, diabetes mellitus, hyperlipidemia, and peripheral vascular disease. She described the pain as very different from any pain that she had experienced in the past. It had a burning quality, was located across her epigastrium and chest, persisted for 4 to 6 minutes at a time, and had been intermittent for 24 hours. The pain came on at rest and was relieved by activity. She reported no associated dyspnea, diaphoresis, or nausea. Review of systems revealed 1 week of constipation. Dr. M., a moonlighting internist, was awakened from sleep to evaluate the patient. Physical examination revealed a pulse of 85 beats/min, blood pressure of 140/70 mm Hg, and respiratory rate of 18 breaths/min. The lungs were clear to auscultation, and heart sounds were normal, with no rubs, murmurs, or gallops. The ECG (obtained during a painful episode) was interpreted as sinus rhythm, with normal axis and normal intervals (Figure 1, top). Dr. M. noted a Q wave in lead III but specically noted the absence of ST-segment and T-wave changes consistent with ischemia. The patient was discharged from the emergency department 1 hour later with a diagnosis of chest and abdominal pain secondary to constipation. She was prescribed a regimen to relieve constipation and was told to schedule a follow-up appointment with her primary physician.

DIAGNOSING CHEST PAIN DEPARTMENT

IN THE

EMERGENCY

Few diagnostic decisions have been more heavily researched than the approach to the patient with acute chest

Improving Patient Care is a special section within Annals supported in part by the U.S. Department of Health and Human Services (HHS) Agency for Healthcare Research and Quality (AHRQ). The opinions expressed in this article are those of the authors and do not represent the position or endorsement of AHRQ or HHS. *This paper was prepared by Lee Goldman, MD, and Ajay J. Kirtane, MD, for the Quality Grand Rounds Series. Kaveh G. Shojania, MD, prepared the case for presentation. The case and discussion were presented at the 2002 Annual Session of the American College of Physicians in Philadelphia, Pennsylvania, on 1114 April 2002. 2003 American College of Physicians 987

Improving Patient Care

Triage of Patients with Acute Chest Pain and Possible Cardiac Ischemia

Figure 1. Electrocardiograms (ECGs) obtained at presentation and a previous comparison tracing.

Top. The ECG shows tracing obtained at initial presentation (and obtained during an episode of chest pain) at half-standard scale. Bottom. The ECG shows tracing at standard scale from several years before the current presentation. It was available for comparison at the time of presentation, although the difference in ECG standardization was not noted at that time despite the presence of standardization marks. Subsequent recognition of this difference between the 2 tracings presumably contributed to the cardiologists interpretation of the new ECG as abnormal, with new J-point depression anterolaterally (V2 to V5).

pain. In the context of the patient safety movement, it is useful to consider this case not only for what it teaches us about triaging patients with acute chest pain but also for what it may reveal about improving the individual physicians diagnostic performance through the use of algorithms or protocols. Chest pain accounts for about 5.6 million emergency department visits annually, second only to abdominal pain as the most common reason for an emergency department visit. Approximately 1% to 4% of patients who present to an emergency department with what is actually an acute MI are mistakenly discharged (1 8), and the percentage of missed diagnoses increases when the denominator includes not only acute MI but also unstable angina. Patients discharged from the emergency department with MI have a generally worse prognosis than do appropriately hospital988 16 December 2003 Annals of Internal Medicine Volume 139 Number 12

ized patients with MI (1 4), partly because of their risk for sudden death but also because of the delay in implementing treatments that are known to be effective for MI or the acute coronary syndrome (unstable angina or nonST-elevation MI). Patients with atypical symptoms, and especially patients without chest pain (2, 3), are most likely to be mistakenly discharged. The clinical question is which patients with acute chest pain have a presentation benign enough to make discharge from the emergency department safe and appropriate. Cost-effectiveness analyses suggest that a coronary care unit is the appropriate triage option for patients whose probability of acute MI is about 20% or higher (9, 10). For patients whose risks for MI or acute coronary ischemia are lower (5 8, 11), admission to telemetry units is often recommended, including a short stay on a chest pain (or corwww.annals.org

Triage of Patients with Acute Chest Pain and Possible Cardiac Ischemia

Improving Patient Care

onary) evaluation or observation unit. In analyzing Mrs. T.s presentation, it is essential to determine whether any combination of initial symptoms, signs, laboratory studies, or ECG ndings has enough discriminatory power to reduce the likelihood of misdiagnosing an acute coronary syndrome to a level that would render discharge from the emergency department safe and appropriate. In the acute setting, the ECG is not only the most important piece of information (12), it is nearly as important as all other information combined. About 80% of patients with acute MI have an initial ECG that shows evidence of infarction or ischemia not known to be old (Figure 2), and any patient who has such abnormalities has too high a risk to be safely discharged, regardless of the clinical history or physical examination (13, 14). The sensitivity is lower if the goal is to identify ischemia in addition to infarction, but comparisons with previous ECGs can improve the accuracy and usefulness of interpreting the ECG (15). Although a normal ECG at presentation predicts a relatively lower risk for complications (16 18), it cannot absolutely exclude myocardial ischemia or even MI. For example, among patients mistakenly discharged from the emergency department, up to 50% have normal or nondiagnostic ECG ndings (2, 19). Thus, even if Mrs. T.s ECG had been normal or unchanged from her previous ECG, this would not have had enough negative predictive value to exclude an acute MI or the acute coronary syndrome. The description of the presenting symptom is also important. Patients with chest pain are more likely to have MI or the acute coronary syndrome (7, 8, 11, 14), but up to 25% of patients with these diagnoses may present with symptoms such as shortness of breath, dizziness, or weakness, so cardiac ischemia must also be considered in patients with these symptoms. Demographic factors and traditional cardiovascular risk factors (with the very notable exception of a history of MI or coronary disease [5, 6, 20, 21]) are of little importance in predicting the cause of acute chest pain (2124). Aspects of the medical history that appreciably lower the patients likelihood of ischemia (likelihood ratios of approximately 0.2) include reproducibility of pain with palpation or positional changes, pleuritic pain, stabbing pain, or pain radiating to the lower extremities (5, 6, 20, 21, 24). However, even these negative predictors cannot reliably exclude MI (20, 25). Mrs. T.s description of painful episodes lasting only 4 to 6 minutes may also seem atypical, but the duration of symptoms is not a useful predictor (5, 79) unless the pain has persisted for 48 hours or more without ECG changes (5, 6). Patients who describe their pain as similar to previous episodes of cardiac ischemia are in a high-risk category (5, 18), but any chest pain carries a higher risk than no pain (7, 8, 11). Although the precise reproduction of chest pain by local palpation decreases risk (5, 18), normal results on physical examination do not lower the risk (5, 18, 20, 24). How can these data have been used in caring for Mrs. T.? She had pain that was different from her previous MI and was thought to have an unchanged ECG. If it is aswww.annals.org

Figure 2. Receiver-operating characteristic curve of the initial electrocardiographic interpretation.

The cumulative sensitivity (number of patients with myocardial infarction [MI] divided by all patients with MI) of electrocardiographic interpretations is on the y-axis and is plotted against the cumulative falsepositive rate (number of patients without MI divided by all patients without MI) on the x-axis. New is dened as not known to be old. Reproduced from Rouan et al. (13).

sumed that all of these data are accurate, she would have had less than a 7% risk for MI and a low risk for complications that would require intensive care (18). However, because of her history of coronary disease and the absence of a clear-cut benign diagnosis, because constipation is not an established cause of chest pain, and because her pain had not resolved, she is the type of patient for whom admission to a chest pain evaluation unit is appropriate (20, 21, 26 33) (Table). It is very important for individual hospitals to adopt clear guidelines for triaging such patients, because these patients may be evaluated by many different physicians with varying experience, knowledge, personality traits, and levels of fatigue (8, 34, 35).
Dr. M.: I think one of the factors that affected my decision making when I rst evaluated the patient was the time of night (2:00 a.m.) and the fact that I had just awakened. I saw her less than a minute after being awakened. What I probably should have done was had her stay in the emergency department, even if I thought she was low risk (which I obviously at that time did), and let more time pass so that my sleep inertia could wear off.

Many studies have documented the effect of fatigue on the cognitive performance of physicians (36) and other workers (37). Although fatigue is clearly a safety issue (38), strategies to reduce fatigue must be planned carefully to avoid adverse collateral effects. For example, a beforeafter study of the effects of regulations on residents work hours in New York after the Libby Zion case revealed no change
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Triage of Patients with Acute Chest Pain and Possible Cardiac Ischemia

Table. Recommended Strategies for Determining Where To Admit Patients with Acute Chest Pain for Treatment of Ongoing Life-Threatening Conditions*
Location Intensive care unit Indication One of the following: Substantial ischemic ECG changes in 2 or more leads that are not known to be old ST-segment elevation 1 mm or Q-waves of 0.04 s or more ST-segment depression 1 mm or T-wave inversion consistent with the presence of ischemia Any 2 of the following conditions, with or without substantial ECG changes: Coronary artery disease known to be unstable (in terms of frequency, duration, intensity, or failure to respond to usual measures) Systolic blood pressure 100 mm Hg Serious new arrhythmias (new-onset atrial fibrillation, atrial flutter, sustained supraventricular tachycardia, second-degree or complete heart block, or sustained or recurrent ventricular arrhythmias) Rales above the bases Any of the following conditions but not meeting criteria for intensive care: Coronary artery disease known to be unstable Systolic blood pressure 110 mm Hg Rales above the bases Major arrhythmias (new-onset atrial fibrillation, atrial flutter, sustained supraventricular tachycardia, second-degree or complete heart block, or sustained or recurrent ventricular arrhythmias) New-onset typical ischemic heart disease that meets the clinical criteria for unstable angina and that occurs at rest or with minimal exertion New-onset symptoms that may be consistent with ischemic heart disease but are not associated with ECG changes or a convincing diagnosis of unstable ischemic heart disease at rest or with minimal exertion Known coronary artery disease whose presentation does not suggest a true worsening but for which further observation is thought to be beneficial, commonly because a benign diagnosis cannot be established Other conditions

Intermediate care unit

Evaluation or observation unit

Home with office follow-up in 7 to 10 days to determine whether further testing is needed

* ECG

electrocardiogram. Adapted with permission from Lee and Goldman (12). Copyright 2000 Massachusetts Medical Society. All rights reserved.

in hospital mortality after implementation of the new regulations but found delays in test ordering and an increase in complications (39), presumably because of the increase in handoffs. Improving the sign-out and handoff of patients can reduce the risk that discontinuity will worsen the quality of care (40, 41).

THE CASE, CONTINUED

Mrs. T. was discharged from the emergency department. Three hours later (5:00 a.m.), she called the telephone triage service for her doctors practice and informed the nurse that she had been seen in the emergency department for chest pain during the night, at which time her ECG was normal and the diagnosis was constipation. She added that she had had 2 bowel movements after taking milk of magnesia, but her symptoms had persisted. The nurse advised her to obtain a new bottle of sublingual nitroglycerin and to return to the emergency department should the pain continue or should new symptoms develop.

contact health care providers can delay the care of patients with the acute coronary syndrome by delaying emergency medical services and the arrival of such patients in the emergency department (46, 47). In a recent survey of primary care after-hours telephone-answering services, physician reviewers reported that patients were frequently asked to decide for themselves whether problems were emergent enough to contact the on-call physician and that 50% of calls not forwarded to the physician were emergencies that warranted immediate contact (48). A patient who does not improve after initial treatment may have received the wrong diagnosis and treatment and therefore deserves reevaluation (42 45). In this case, well-meaning triage nurses seem to have relied on the patients willingness to be reassured rather than insisting that the patient come to the emergency department for immediate evaluation (in the call 12 hours before the emergency department visit) and then relied on the clean bill of health from the emergency department physician in reassuring the patient (in the call after the emergency department visit).

THE TELEPHONE: FALSE REASSURANCE?

Recently, the availability of benecial therapies for acute coronary syndromes has led to several initiatives to reduce delays between the onset of symptoms and the provision of denitive care. Given the importance of the ECG for both diagnosis and prognosis, triage systems should recommend immediate in-person evaluation of virtually all patients with a presenting symptom of chest pain, preferably in an emergency department (20, 42 45). Attempts to
990 16 December 2003 Annals of Internal Medicine Volume 139 Number 12

THE CASE, CONTINUED

At 7:00 a.m., approximately 2 hours after the second call to the telephone service, the patient returned to the emergency department where she was again assessed by Dr. M., who was now approaching the end of his shift. Before going off duty, the physician ordered a GI [gastrointestinal] cocktail, screening hematology and chemistry tests, a troponin I level measurement, chest radiography, and electrocardiography. At 10:00
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Triage of Patients with Acute Chest Pain and Possible Cardiac Ischemia

Improving Patient Care

a.m., a new physician came on shift and noted that the patient had no symptoms. One hour later, however, the results of the 0.3 troponin I test came back at 2.0 g/L (normal level, g/L), thus conrming the diagnosis of MI. The patient immediately received a chewable aspirin and intravenous metoprolol and was placed on a cardiac monitor. The note from the new physician reafrmed Mrs. T.s symptoms and reported normal results on physical examination, but now Mrs. T.s new ECG was interpreted as showing pseudonormalization of the T wave in V6 compared with a previous ECG in 1998 (Figure 1, bottom). The patient was admitted to the cardiology service with the diagnosis of acute MI, although the physicians note specically called the presentation very atypical. An attending cardiologist later reviewed the ECG from the 2:00 a.m. visit to the emergency department (Figure 1, top) and interpreted it as abnormal, with new J-point depression anterolaterally (V2 to V5), compared with the previous ECG. In fact, the ECG showed about 0.5-mm ST-segment depression on half-standard voltage, roughly equivalent to 1 mm on a regular standard ECGa nding consistent with ischemia compared with the baseline tracing.

THE ELUSIVENESS

OF

DIAGNOSTIC PERFECTIBILITY

The modern approach to patient safety emphasizes systems thinking rather than individual cognitive mistakes or technical slips. The goal is to create processes and solutions to prevent human errors, which are commonly made by competent individuals (49, 50). Suggested approaches include diagnostic protocols and pathways, decision aids, novel approaches to stafng, and other systems changes. Several factors have been associated with inappropriate discharge of patients with chest pain from emergency departments: younger age, female sex, non-white ethnicity, atypical symptoms, no previous MI, and normal or nearnormal ECGs (1 4, 5157). Since about 25% of patients who are mistakenly discharged are sent home because of an error in the interpretation of their ECG (13), improving the analysis and interpretation of ECGs could improve decision making (8, 58 62). In this case, more accurate interpretation of the initial ECG might have prevented the patients discharge from the emergency department. Can further training or the use of decision algorithms help solve the problem of missed ischemia or MI? Standardizing ECG interpretations by traditional computer analysis (8, 63 65) or articial neural network technology (66 68), and incorporating these interpretations into clinical decision making, theoretically could reduce diagnostic error. Several strategies have been used to attack this problem. Pozen and Selker and their respective colleagues (7, 8, 11) have developed models to predict coronary ischemia (encompassing acute MI and the acute coronary syndrome) because of its broad clinical relevance, whereas Goldman and colleagues (5, 6) tried to predict the probability of MI because it is more precisely dened and carries the highest
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risk. Eventually, Goldman and colleagues (18) switched to predicting the need for intensive care or other levels of care because it seemed to be the critical triage decision facing physicians. Early data demonstrated that physicians with higher levels of training had a higher sensitivity for detecting MI, but at the expense of decreased specicity consistent with a shift along the same receiver-operating characteristic curve (34). Although several decision aids have good predictive power (5, 8, 18, 21), implementing them in clinical practice has generally demonstrated little or no overall improvement in triage decisions (69 78), except by trainees (8). Low-intensity interventions, such as chart reminders and guidelines, have been difcult to implement (76, 78). However, a predictive model with an automatic ECG interpretation can increase the use of brinolytic therapy for acute ST-elevation MI, especially in historically undertreated patients (79). Alternatively, Cook County Hospital in Chicago, Illinois, developed a consensus to adapt and implement Goldman and colleagues (18) intensive care triage algorithm (75). This resulted in a highly statistically and clinically signicant 15% absolute reduction and 39% relative reduction in the triage of uncomplicated patients to unnecessarily intensive settings without a corresponding reduction in the admission of patients with complications to appropriately intensive settings. These 2 approachesincorporating validated predictive instruments into the ECG reading, or using validated predictive models to develop and implement local consensus guidelines deserve more widespread testing to determine their broader generalizability. However, any algorithm that incorporates only clinical elements and the ECG at presentation is likely to be suboptimal because of the substantial proportion of patients who present with atypical symptoms or no or minimal ECG changes. Widely available biomarkers (such as creatine kinaseMB assays and troponin T and troponin I levels) have low sensitivities for the diagnosis of MI when measured at the initial presentation to the emergency department, particularly within 6 hours of the onset of symptoms (12, 80). Although normal levels of these biomarkers cannot exclude unstable angina by denition, a condition without myocyte necrosisthe nding of serially negative biomarker levels at presentation and 6 hours later identies patients at low risk for further complications, particularly when combined with a normal or nondiagnostic ECG (12, 81, 82). Whether Mrs. T.s initial troponin level would have been positive when she presented 12 hours after the onset of her pain is unknown. The key issue for diagnosis is not that an initially positive biomarker level is unhelpfulin fact, it mandates admission but rather that the decision to measure and assess a biomarker level at presentation implies that the patients risk is high enough to require a repeated assessment 6 hours later if the rst level is normal. Studies of immediate exercise stress testing, echocardiography, and routine predischarge coronary angiography
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Triage of Patients with Acute Chest Pain and Possible Cardiac Ischemia

have demonstrated good negative predictive values in lowto moderate-risk patients who have symptoms consistent with acute cardiac ischemia (51, 83 88). In a large randomized trial, prompt resting sestamibi scans statistically signicantly reduced unnecessary admissions without changing appropriate admissions when used in patients with suspected ischemia and normal or near-normal ECG ndings (89). However, most of these strategies have excluded patients with a previous MI and none have been widely adopted. The sobering bottom line is that 2 decades of research has taught us that without compelling evidence for a noncardiac cause, there is no absolutely fail-safe way to exclude myocardial ischemia or infarction at the time of a patients initial presentation. A short period of monitoring and measuring serial biomarker levels in a chest pain evaluation unit is an attractive approach for patients with an uncertain diagnosis. Although there may be substantial variations in the rates at which MI or the acute coronary syndrome are missed at individual hospitals (2), the missed MI rate is generally inversely proportional to the rule-in rate (90). Observing more patients in chest pain units can reduce the rate of missed MIs to less than 1% (90) and still allow expedited diagnosis and evaluation of a large number of low-risk patients. Rapid protocols and chest pain units are cost-effective alternatives to regular hospitalization for lowrisk patients (26, 31, 32, 91, 92). Many experts recommend routine exercise or other provocative testing after 6 hours of observation, but data to support this practice are limited. Chest pain units can incorporate educational and community outreach programs focused on cardiovascular disease (27, 28, 32) and can improve patients satisfaction (29). Chest pain units are also an ideal location to study decision algorithms and new strategies for diagnosis and therapy (93). These specialized units can standardize the clinical assessment and the interpretation of the ECG by training and employing a limited number of personnel. Given the profound adverse clinical outcomes and high malpractice awards associated with missed MI, chest pain units increase the likelihood that patients are truly safe for discharge. When Dr. Goldman, the lead author of this paper, rst began researching patients with acute chest pain more than 20 years ago, he believed that he and others could identify a set of clinical and ECG ndings that would more accurately identify actual MIs than the physicians who actually saw these same patients. However, the ensuing years of research (18, 94) have revealed that there is no single way to discriminate perfectly between those who should be admitted to a coronary care unit and those who should be sent home. Instead, there is a continuum of riska nding that suggests that there also should be a range of triage options to match not only the diversity of risks but also the differences in the levels of care and monitoring among individual hospitals (32). From this appreciation came the expanded use of step-down units, beginning with their
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original focus on moderate-risk patients (9) and then, with the development of chest pain (or coronary) evaluation (or observation) units, a refocus on patients whose risks were even lower, yet not low enough to ensure the safety of immediate discharge (26 33, 90 93). What we have done, in essence, is to take the dollars saved per patient from these shorter observation protocols (as compared with the resource intensive, multiday rule-out MI admission of the past generation) and used them to admit more lowrisk patients, thereby decreasing the missed MI error rate (90).

THE RESPONSE

TO THE

CASE

Dr. M.: I told the patient, when she came back about 3 hours later, that she was in fact having an MI, that she probably had been having an MI 3 hours earlier, and that I had misread her ECG. . . . I apologized to her. She did not think that there was much harm from the 3-hour-or-so delay and was very forgiving. . . . My junior colleagues were uniformly appreciative of my sharing the error, and they told me it helped create an atmosphere in which they felt more comfortable discussing their own errors. Our chairman was very supportive. He said that he was proud that I had been willing to discuss the error openly and hoped that this kind of disclosure would continue throughout our entire department. I think when we think about systems issues around errors, it is easy enough to say that we shouldnt point ngers at individuals and we should look at the system overall. While I felt that this error was in some ways personal, I dont think of myself as an incompetent physician. Unfortunately, . . . beyond identifying, in retrospect, that the abnormality in the rst ECG was probably underappreciated, I dont think that we, as a group, came up with any solutions. Again, I think the main kinds of solutions could be better training for me or other people in my position, possibly having other providers around who could have evaluated the ECG. But it was hard to come up with a simple solution of how we could prevent this kind of error in the future.

HONESTY

AS A

TRIGGER

FOR

CHANGE

If it aint broke, dont x it is a popular aphorism in response to decisions about allocating scarce resources. Identifying and eradicating suboptimal care, assessing problems honestly, and committing to improving both personal performance and systems of care are cornerstones of a physicians responsibility to individual patients and to society. Recognizing an error and sharing the error with the patient and other physicians affords us and others the opportunity to recognize that errors do indeed occur, and that we can strive to become better physicians by learning from them. Mistakes must be opportunities for progress, not punishment.
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Triage of Patients with Acute Chest Pain and Possible Cardiac Ischemia
From the University of California, San Francisco, San Francisco, California.
Grant Support: Funding for the Quality Grand Rounds series is sup-

Improving Patient Care

ported by the California HealthCare Foundation as part of its Quality Initiative.

Potential Financial Conflicts of Interest: None disclosed. Requests for Single Reprints: Lee Goldman, MD, Department of Medicine, University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143-0120.

Current author addresses are available at www.annals.org.

References
1. McCarthy BD, Beshansky JR, DAgostino RB, Selker HP. Missed diagnoses of acute myocardial infarction in the emergency department: results from a multicenter study. Ann Emerg Med. 1993;22:579-82. [PMID: 8442548] 2. Pope JH, Aufderheide TP, Ruthazer R, Woolard RH, Feldman JA, Beshansky JR, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med. 2000;342:1163-70. [PMID: 10770981] 3. Lee TH, Rouan GW, Weisberg MC, Brand DA, Acampora D, Stasiulewicz 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: 219-24. [PMID: 3618483] 4. Schor S, Behar S, Modan B, Barell V, Drory J, Kariv I. Disposition of presumed coronary patients from an emergency room. A follow-up study. JAMA. 1976;236:941-3. [PMID: 988893] 5. Goldman L, Cook EF, Brand DA, Lee TH, Rouan GW, Weisberg MC, et al. A computer protocol to predict myocardial infarction in emergency department patients with chest pain. N Engl J Med. 1988;318:797-803. [PMID: 3280998] 6. Goldman L, Weinberg M, Weisberg M, Olshen R, Cook EF, Sargent RK, et al. A computer-derived protocol to aid in the diagnosis of emergency room patients with acute chest pain. N Engl J Med. 1982;307:588-96. [PMID: 7110205] 7. Pozen MW, DAgostino RB, Selker HP, Sytkowski PA, Hood WB Jr. A predictive instrument to improve coronary-care-unit admission practices in acute ischemic heart disease. A prospective multicenter clinical trial. N Engl J Med. 1984;310:1273-8. [PMID: 6371525] 8. Selker HP, Beshansky JR, Grifth JL, Aufderheide TP, Ballin DS, Bernard SA, 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;129:845-55. [PMID: 9867725] 9. Fineberg HV, Scadden D, Goldman L. Care of patients with a low probability of acute myocardial infarction. Cost effectiveness of alternatives to coronary-careunit admission. N Engl J Med. 1984;310:1301-7. [PMID: 6425687] 10. Tosteson AN, Goldman L, Udvarhelyi IS, Lee TH. Cost-effectiveness of a coronary care unit versus an intermediate care unit for emergency department patients with chest pain. Circulation. 1996;94:143-50. [PMID: 8674172] 11. Selker HP, Grifth JL, DAgostino RB. A tool for judging coronary care unit admission appropriateness, valid for both real-time and retrospective use. A time-insensitive predictive instrument (TIPI) for acute cardiac ischemia: a multicenter study. Med Care. 1991;29:610-27. [PMID: 2072767] 12. Lee TH, Goldman L. Evaluation of the patient with acute chest pain. N Engl J Med. 2000;342:1187-95. [PMID: 10770985] 13. Rouan GW, Lee TH, Cook EF, Brand DA, Weisberg MC, Goldman L. Clinical characteristics and outcome of acute myocardial infarction in patients with initially normal or nonspecic electrocardiograms (a report from the Multicenter Chest Pain Study). Am J Cardiol. 1989;64:1087-92. [PMID: 2683709] 14. Selker HP, Zalenski RJ, Antman EM, Aufderheide TP, Bernard SA, Bonow RO, et al. An evaluation of technologies for identifying acute cardiac ischemia in the emergency department: a report from a National Heart Attack Alert Program Working Group. Ann Emerg Med. 1997;29:13-87. [PMID: 8998086]
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15. Lee TH, Cook EF, Weisberg MC, Rouan GW, Brand DA, Goldman L. Impact of the availability of a prior electrocardiogram on the triage of the patient with acute chest pain. J Gen Intern Med. 1990;5:381-8. [PMID: 2231032] 16. Brush JE Jr, Brand DA, Acampora D, Chalmer B, Wackers FJ. Use of the initial electrocardiogram to predict in-hospital complications of acute myocardial infarction. N Engl J Med. 1985;312:1137-41. [PMID: 3920520] 17. Slater DK, Hlatky MA, Mark DB, Harrell FE Jr, Pryor DB, Califf RM. Outcome in suspected acute myocardial infarction with normal or minimally abnormal admission electrocardiographic ndings. Am J Cardiol. 1987;60:76670. [PMID: 3661390] 18. Goldman L, Cook EF, Johnson PA, Brand DA, Rouan GW, Lee TH. Prediction of the need for intensive care in patients who come to the emergency departments with acute chest pain. N Engl J Med. 1996;334:1498-504. [PMID: 8618604] 19. Pope JH, Ruthazer R, Beshansky JR, Grifth JL, Selker HP. Clinical features of emergency department patients presenting with symptoms suggestive of acute cardiac ischemia: a multicenter study. J Thromb Thrombolysis. 1998;6:6374. [PMID: 10751787] 20. Braunwald E, Antman EM, Beasley JW, Califf RM, Cheitlin MD, Hochman JS, et al. ACC/AHA guideline update for the management of patients with unstable angina and non-ST-segment elevation myocardial infarction2002: 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;106:1893-900. [PMID: 12356647] 21. Braunwald E, Mark DB, Jones RH, Cheitlin MD, Fuster V, McCauley K, et al. Unstable Angina: Diagnosis and Management. Clinical Practice Guideline Number 10. AHCPR Publication no. 94-0602. Rockville, MD: Agency for Health Care Policy and Research; 1994. 22. Jayes RL Jr, Beshansky JR, DAgostino RB, Selker HP. Do patients coronary risk factor reports predict acute cardiac ischemia in the emergency department? A multicenter study. J Clin Epidemiol. 1992;45:621-6. [PMID: 1607901] 23. Zalenski RJ, Shamsa F, Pede KJ. Evaluation and risk stratication of patients with chest pain in the emergency department. Predictors of life-threatening events. Emerg Med Clin North Am. 1998;16:495-517, vii. [PMID: 9739772] 24. Panju AA, Hemmelgarn BR, Guyatt GH, Simel DL. The rational clinical examination. Is this patient having a myocardial infarction? JAMA. 1998;280: 1256-63. [PMID: 9786377] 25. Lee TH, Cook EF, Weisberg M, Sargent RK, Wilson C, Goldman L. Acute chest pain in the emergency room. Identication and examination of low-risk patients. Arch Intern Med. 1985;145:65-9. [PMID: 3970650] 26. Farkouh ME, Smars PA, Reeder GS, Zinsmeister AR, Evans RW, Meloy TD, et al. A clinical trial of a chest-pain observation unit for patients with unstable angina. Chest Pain Evaluation in the Emergency Room (CHEER) Investigators. N Engl J Med. 1998;339:1882-8. [PMID: 9862943] 27. Chest pain evaluation units. American College of Emergency Physicians. Ann Emerg Med. 2000;35:541-4. [PMID: 10783424] 28. Graff L, Joseph T, Andelman R, Bahr R, DeHart D, Espinosa J, et al. American College of Emergency Physicians information paper: chest pain units in emergency departmentsa report from the Short-Term Observation Services Section. Am J Cardiol. 1995;76:1036-9. [PMID: 7484857] 29. Rydman RJ, Zalenski RJ, Roberts RR, Albrecht GA, Misiewicz VM, Kampe LM, et al. Patient satisfaction with an emergency department chest pain observation unit. Ann Emerg Med. 1997;29:109-15. [PMID: 8998089] 30. Gaspoz JM, Lee TH, Cook EF, Weisberg MC, Goldman L. Outcome of patients who were admitted to a new short-stay unit to rule-out myocardial infarction. Am J Cardiol. 1991;68:145-9. [PMID: 2063775] 31. Gaspoz JM, Lee TH, Weinstein MC, Cook EF, Goldman P, Komaroff AL, et al. Cost-effectiveness of a new short-stay unit to rule out acute myocardial infarction in low risk patients. J Am Coll Cardiol. 1994;24:1249-59. [PMID: 7930247] 32. Zalenski RJ, Selker HP, Cannon CP, Farin HM, Gibler WB, Goldberg RJ, et al. National Heart Attack Alert Program position paper: chest pain centers and programs for the evaluation of acute cardiac ischemia. Ann Emerg Med. 2000; 35:462-71. [PMID: 10783408] 33. Nichol G, Walls R, Goldman L, Pearson S, Hartley LH, Antman E, et al. A critical pathway for management of patients with acute chest pain who are at
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1463-7. [PMID: 10993869] 87. Amsterdam EA, Kirk JD, Diercks DB, Lewis WR, Turnipseed SD. Immediate exercise testing to evaluate low-risk patients presenting to the emergency department with chest pain. J Am Coll Cardiol. 2002;40:251-6. [PMID: 12106928] 88. deFilippi CR, Rosanio S, Tocchi M, Parmar RJ, Potter MA, Uretsky BF, et al. Randomized comparison of a strategy of predischarge coronary angiography versus exercise testing in low-risk patients in a chest pain unit: in-hospital and long-term outcomes. J Am Coll Cardiol. 2001;37:2042-9. [PMID: 11419885] 89. Udelson JE, Beshansky JR, Ballin DS, Feldman JA, Grifth JL, Handler J, et al. Myocardial perfusion imaging for evaluation and triage of patients with suspected acute cardiac ischemia: a randomized controlled trial. JAMA. 2002; 288:2693-700. [PMID: 12460092] 90. Graff LG, Dallara J, Ross MA, Joseph AJ, Itzcovitz J, Andelman RP, et al. Impact on the care of the emergency department chest pain patient from the chest pain evaluation registry (CHEPER) study. Am J Cardiol. 1997;80:563-8. [PMID: 9294982] 91. Gomez MA, Anderson JL, Karagounis LA, Muhlestein JB, Mooers FB. An emergency department-based protocol for rapidly ruling out myocardial ischemia reduces hospital time and expense: results of a randomized study (ROMIO). J Am Coll Cardiol. 1996;28:25-33. [PMID: 8752791] 92. Roberts RR, Zalenski RJ, Mensah EK, Rydman RJ, Ciavarella G, Gussow L, et al. Costs of an emergency department-based accelerated diagnostic protocol vs hospitalization in patients with chest pain: a randomized controlled trial. JAMA. 1997;278:1670-6. [PMID: 9388086] 93. Tatum JL, Jesse RL, Kontos MC, Nicholson CS, Schmidt KL, Roberts CS, et al. Comprehensive strategy for the evaluation and triage of the chest pain patient. Ann Emerg Med. 1997;29:116-25. [PMID: 8998090] 94. Lee TH, Juarez G, Cook EF, Weisberg MC, Rouan GW, Brand DA, et al. Ruling out acute myocardial infarction. A prospective multicenter validation of a 12-hour strategy for patients at low risk. N Engl J Med. 1991;324:1239-46. [PMID: 2014037] 95. Fine MJ, Auble TE, Yealy DM, Hanusa BH, Weissfeld LA, Singer DE, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med. 1997;336:243-50. [PMID: 8995086] 96. Niederman MS, Mandell LA, Anzueto A, Bass JB, Broughton WA, Campbell GD, et al. Guidelines for the management of adults with community-acquired pneumonia. Diagnosis, assessment of severity, antimicrobial therapy, and prevention. Am J Respir Crit Care Med. 2001;163:1730-54. [PMID: 11401897]

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APPENDIX: QUESTIONS CONFERENCE

AND

ANSWERS

FROM THE

An audience member: What do you think of the use of telephone triage in this case? Dr. Goldman: Telephone triage can be useful when it is accompanied by well-constructed protocols and guidelines. My guess is that the nurses performing the telephone triage in this case lacked a chest pain protocol, which should have led them to direct virtually all patients with chest pain to come to the emergency department, since there is no combination of clinical variables that trumps a test that can be performed only in the emergency department, namely the ECG. Dr. Robert M. Wachter, Quality Grand Rounds Editor (Moderator): The evolution of your thinking on this issue is fascinatingyou have moved from a hope that we could perfect a diagnostic algorithm in the emergency department to a recognition that the best way to prevent errors is to admit most low-risk patients and then exclude the pos-

sibility of cardiac ischemia as efciently as possible. Is any of this experience generalizable to the management of other disorders, or is chest pain unique? Dr. Goldman: One lesson, which is probably a good one for all of us, is to remain humble and open to changes in our thinking. The chest pain experience is most generalizable to only a few disorders, such as pulmonary embolus, meningitis, or an acute abdomen, that also have such high stakes. For example, one could try to use the Pneumonia Severity Index to discharge low-risk patients to home (95, 96), because for this and many other diseases the adverse consequences of an inappropriate discharge are far less than with chest pain.
Current Author Addresses: Dr. Goldman: Department of Medicine,

University of California, San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143-0120. Dr. Kirtane: Beth Israel Deaconess Medical Center, One Deaconess Road, Boston, MA 02215.

E-996 American College of Physicians