SPECIAL CONTRIBUTION/NATIONAL HEART ATTACK
ALERT PROGRAM
From the Evidence-based Practice
Center, Division of Clinical Care
Research, New England Medical
Center, Boston, MA.
Dr. Ioannidis is now at Department of
Hygiene and Epidemiology, University
of Ioannina School of Medicine,
Ioannina, Greece.
Received for publication July 17, 2000.
Revision received December 29, 2000.
Accepted for publication
February 1, 2001.
This study was conducted by the New
England Medical Center Evidence-
based Practice Center under contract
to the Agency for Healthcare Research
and Quality (formerly, Agency for
Health Care Policy and Research),
contract No. 290-97-0019, Rockville,
MD.
Reprints not available from the
authors.
Address for correspondence: Joseph
Lau, MD, Division of Clinical Care
Research, New England Medical
Center, 750 Washington Street,
Box 63, Boston, MA 02111;
617-636-7670, fax 617-636-8023;
E-mail jlaul@lifespan.org.
Copyright © 2001 by the American
College of Emergency Physicians.
0196-0644/2001/$35.00 + 0
47/1/114901
doi:10.1067/mem.2001.114901
MAY 2001 37:5 ANNALS OF EMERGENCY MEDICINE
Accuracy of Imaging Technologies in the
Diagnosis of Acute Cardiac Ischemia in the
Emergency Department: A Meta-Analysis
John P. A. Ioannidis, MD See related articles, p. 450, p. 453, p. 461, and p. 478.
Deeb Salem, MD
Priscilla W. Chew, MPH
Study objective: We sought to quantitatively evaluate the
Joseph Lau, MD
evidence on the diagnostic performance of imaging technologies
(including rest and stress echocardiography and technetium-99m
sestamibi scanning) for the diagnosis of acute cardiac ischemia
and acute myocardial infarction in the emergency department.
Methods: We conducted a systematic review and meta-analy-
sis of the English-language literature published between 1966
and December 1998. Both prospective and retrospective studies
qualified for the assessment of diagnostic performance. Diag-
nostic performance was assessed by means of random-effect
estimates of test sensitivity, specificity, and the diagnostic odds
ratio and was summarized by using summary receiver-operating
characteristic curves.
Results: Diagnostic accuracy was evaluated in 10 studies of
rest echocardiography, 2 studies of dobutamine stress echocar-
diography, and 6 studies of technetium-99m sestamibi scanning.
However, only 3 rest echocardiography and 5 technetium-99m
sestamibi studies evaluated patients strictly in the ED setting.
Patient populations were often highly selected to represent low-
or moderate-risk groups. When limited to ED studies, rest echo-
cardiography showed excellent sensitivity of 93% (95% CI, 81%
to 97%) and good specificity of 66% (95% CI, 43% to 83%). The
results were similar when all studies were considered, includ-
ing data from reports of admitted patients and patients sent to
the cardiac care unit. There was insufficient literature on stress
echocardiography in the ED to properly assess the technology.
Technetium-99m sestamibi scanning also showed excellent sen-
sitivity (range, 91.5% to 100%) and good specificity (range,
49.3% to 84.4%) for acute myocardial infarction; for acute car-
diac ischemia, the random-effects pooled sensitivity was 89%
(95% CI, 73% to 96%), and the pooled specificity was 77%
(95% CI, 63% to 87%).
4 7 1
IMAGING TECHNOLOGIES AND ACUTE CARDIAC ISCHEMIA
Ioannidis et al

Conclusion: For selected low- and moderate-risk patient
groups, echocardiography and technetium-99m sestamibi imag-
ing appear to have very good diagnostic performance with a
similar sensitivity and specificity profile. More evidence should
be accumulated on their performance specifically in the ED
setting.
[Ioannidis JPA, Salem D, Chew PW, Lau J. Accuracy of imaging
technologies in the diagnosis of acute cardiac ischemia in the
emergency department: a meta-analysis. Ann Emerg Med. May
2001;37:471-477.]
INTRODUCTION
Echocardiography and nuclear scans with technetium-
99m sestamibi scanning offer 2 noninvasive options for
the assessment of patients with suspected acute cardiac
ischemia (ACI). At the time evidence on these imaging
modalities was reviewed for the original report of the
National Heart Attack Alert Program data were sparse.1
Several studies on these imaging modalities have been
published in the past 5 years, and the accumulated evi-
dence is amenable to meta-analysis. The present meta-
analysis therefore aimed at estimating the overall sensitiv-
ity and specificity of these modalities for patients in the
ED setting. Because a substantial number of studies for
echocardiography had also been performed in patients
presenting with suspected ACI, although not strictly in
the emergency department setting, we also performed
sensitivity analyses including all these studies.
Details on methods for the systematic review and
general study selection criteria for the meta-analysis are
presented in the accompanying synopsis of the evidence
report on ACI.2 The characterization of population cate-
gory and study quality assessments are also based on
algorithms described in the synopsis.2
REST AND STRESS ECHOCARDIOGRAPHY
A total of 11 reports were considered for the assessment of
the diagnostic accuracy of echocardiography.3-13 Two of
these reports dealt with both rest and dobutamine stress
echocardiography,9,10 8 dealt with rest echocardiography
only,3-7,11-13 and 1 dealt with dobutamine stress echocar-
diography only.8 The 2 publications by Trippi et al9,10
pertain to the same study, and the earlier one describes
the first 26 patients of the later publication. Complemen-
tary information is provided.
With the exception of those by Sabia et al,6 Mohler et
12 and Horowitz et al, 3 all studies required normal or
al,
nondiagnostic ECGs as an inclusion criterion. Trippi et
al10 and Gibler et al13 also required normal cardiac en-
zyme levels. Gibler et al13 performed echocardiograms
only after serial enzymes and serial ECGs had been nor-
mal for 9 hours; this is a very selected population. A past
history of acute myocardial infarction (AMI) was an
exclusion criterion for Peels et al,5 Trippi et al,10 Gibler et
al,13 Sasaki et al,4 and Horowitz et al,3 and at least the first
3 studies also excluded patients with any history of coro-
nary artery disease (CAD) or ACI. Almost all the patients
in the study by Mohler et al12 had previous echocardio-

Table 1.
Characteristics of studies of rest echocardiography in the ED.

Subjects Mean Male Inclusion

Evaluated Age Sex (Exclusion) Blinding
Study (Enrolled) (y) (%) Criteria Test Criteria Performed Potential Bias

Peels et al, 19905 43 (43) 54 74 No data (ECG diagnostic for ACI, Asynergy in at least 1 segment and Test No data
history of CAD or AMI) 11 of 13 segments interpretable
Sabia et al, 19916 169 (180) 62 52 Men >30 y, women >40 y; Regional wall-motion abnormality Test Excluded 22 patients without a
cardiac-related chest pain, in any of 12 segments second creatine kinase level;
acute dyspnea, or both within additional 11 had technically
30 min to 4 h of presentation inadequate echocardiography
Kontos et al, 199811 185 (186) 51 49 Low- or moderate-risk patients Asynergy of 2 contiguous segments, Test and One patient had unreadable
(ECG diagnostic of ACI) wall-motion abnormality of 1 outcome echocardiogram
segment visible in 2 views, or
global hypokinesis with moderate-
to-severe systolic dysfunction

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IMAGING TECHNOLOGIES AND ACUTE CARDIAC ISCHEMIA
Ioannidis et al
grams for comparison to avoid misinterpretation of old
abnormalities.
The diagnosis of AMI was based on World Health
Organization criteria or variants thereof, but several stud-
ies seemed to depend entirely on cardiac enzyme levels.
More broadly defined coronary syndromes were studied
by Kontos et al,11 Sasaki et al4 (AMI or CAD by angiography
or stress test), Peels et al5 (AMI or positive angiography),
Trippi et al10 (AMI or CAD by catheterization or telephone
survey), and Gibler et al13 (any cardiac disease).
Only 3 rest echocardiography studies met the inclusion
criteria of being performed exclusively in the ED setting
(Table 1).5,6,11 The prevalence of AMI for these studies
ranged from 3% to 30% (Table 2). There was little variation
in the sensitivity estimates, and thus the summary receiver-
operating characteristic method is not useful. The com-
bined random-effects model sensitivity and specificity are
calculated in Table 2. The combined random-effects diag-
nostic odds ratio is 20 (95% CI, 6.5 to 62).
Two studies provided data for a broad ACI definition
for diagnostic performance.5,11 By combining their data,
the random-effects diagnostic odds ratio is 17 (95% CI,
7.1 to 39).
Several studies did not meet the strict inclusion criteria
of being performed only in the ED. Echocardiography on
these patients was performed only on admitted patients,
patients in the cardiac care unit (CCU) setting, or both.
Because these studies are the majority of the available evi-
dence and the imaging could have been done theoreti-
cally in the ED just as well, sensitivity analyses addressed
their inclusion.
The quantitative synthesis for rest echocardiography
for AMI is shown in Figure 1A. Pooled estimates of sensi-
Table 2.
Diagnostic performance of rest echocardiography for AMI in the ED.
Study
Study Size
Peels et al, 19905 43
Sabia et al, 19916 169
Kontos et al, 199811 185
Overall 397
*Category I studies included patients with symptoms suggestive of ACI; category III studies included patients with nondiagnostic ECGs. See accompanying synopsis article.2
†
Study quality A articles are high-quality, well documented, unbiased studies. Study quality B articles are fair quality and incompletely documented, with no evidence of significant bias. Study quality
C articles are poor quality and poorly documented, with possibly significant bias. See accompanying synopsis article.2
‡Results of meta-analyses (95% CI) with random-effects calculations.
MAY 2001 37:5 ANNALS OF EMERGENCY MEDICINE
tivity and specificity are inappropriate for synthesizing
these data. Not included are data from Levitt et al7 (data
expressed as mean and SD of wall-motion scores) and
Gibler et al13 (AMI outcome not pertinent given the study
design). Of note, Levitt et al7 found no difference in echo-
cardiographic scores between the AMI and non-AMI
groups (mean, 16.9 versus 15.3; P=.32).
For accuracy in the diagnosis of ACI, the pertinent data
are summarized in Figure 1B. The synthesis includes data
from 4 studies.4,5,11,12 The performance is almost the
same as for AMI (unweighted area under the curve [AUC],
0.90; weighted AUC, 0.89). Inclusion of data on any car-
diac disease by Gibler et al13 would not affect the AUC
estimates (0.91 and 0.89, respectively). Again, simple
pooling of sensitivity and specificity estimates would
underrate the test performance. The use of diverse and
suboptimal reference standards may affect the estimate of
diagnostic performance of echocardiography.
Two reports9,10 addressed both rest and dobutamine
stress echocardiography, and one8 addressed dobutamine
stress echocardiography only (comparing video versus
digital recording of dobutamine stress echocardiograms).
Two reports pertain to the same study.9,10
In the study by Trippi et al,10 all patients had been
admitted to the CCU. The study reported a sensitivity of
89% and a specificity of 89% against AMI or CAD, as
determined by history, catheterization, or telephone
survey. This is a highly selected population who had
nondiagnostic ECGs, normal enzyme levels, mild or no
pain at the time of the study, and negative rest echocar-
diography results. Several discrepancies in the pre-
sented data were found in this study (data in text and
tables disagree).
Test Performance
Population Prevalence Sensitivity Specificity Study
(Setting)* of AMI (%) (%) (%) Quality†
III 30 93 53 C
I 17 93 57 B
III 3 100 82 B
III 3–30 93 (81–97)‡ 66 (43–83)‡ B
4 7 3
IMAGING TECHNOLOGIES AND ACUTE CARDIAC ISCHEMIA
Ioannidis et al

The study by Mohler et al8 suggests that there is excel-
lent concordance between video and digital evaluation of
dobutamine stress echocardiograms.
The sample size of the studies combined in this meta-
analysis is relatively small, especially when only ED stud-
ies are considered. Nevertheless, the existing evidence
suggests that rest echocardiography can have very good
and probably excellent performance in the diagnosis of
AMI and ACI in selected groups of patients. The data per-
tain mostly to patients at low risk of AMI who have normal
or nondiagnostic ECGs. Stress dobutamine echocardiog-
raphy data are very sparse, and no data have been derived
directly from the ED setting. The clinical effect of these
tests is unknown.
T E C H N E T I U M - 9 9 M S E S TA M I B I I M A G I N G
Ten articles pertaining to imaging in the ED setting were
retrieved, but they represent only 5 distinct studies. First,
the Virginia Commonwealth University team produced 4
overlapping reports.11,14-16 The second report includes
all the patients of the first report, and the third and fourth
reports include subsets of the second report in addition to
new subjects. Therefore, we considered only the last 3
reports for the data synthesis. Sensitivity analyses yielded
similar results.
Similarly, 3 reports originated from the William Beau-
mont Hospital.17-19 The report by Stewart et al19 contains
an update of the previous reports, and therefore, only this
report was considered in the synthesis.
The article by Hilton et al20 includes the same patient
population as an earlier report. Therefore, the earlier re-
port is used in the evidence synthesis.21 Finally, the arti-
cle by Varetto et al22 was mentioned in the original
National Heart Attack Alert Program Working Group
report, but it was also noted that only patients admitted to
the CCU were studied. This study was not included in the
main analysis, but a sensitivity analysis addressed its
inclusion.
With these clarifications, 5 studies addressed the diag-
nostic accuracy of technetium-99m sestamibi scanning in
ED patients with chest pain (Table 3). With one exception,

Figure 1.
A, Summary receiver-operating characteristic curve analysis of rest echocardiography in the diagnosis of AMI. B, Summary receiver-oper-
ating characteristic curve analysis of rest echocardiography in the diagnosis of ACI. All retrieved studies are included, regardless of whether
they were performed entirely in the ED. Plotted in each of the summary receiver-operating characteristic graphs are individual studies
depicted as ellipses. The x- and y-dimensions of the ellipses are proportional to the square root of the number of patients available to study
the specificity and sensitivity, respectively, within the analysis. Also shown is the unweighted summary receiver-operating characteristic
curve limited to the range where data are available. The cross (x) represents the independent random-effects pooling of sensitivity and
specificity values of the studies.

A Sensitivity B Sensitivity
100 100
90 90

80 80

70 70

60 60

50 50

40 40

30 30
20 20

10 10

0 0
0 10 20 30 40 50 60 70 80 90 100 0 10 20 30 40 50 60 70 80 90 100
100–Specificity 100–Specificity

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IMAGING TECHNOLOGIES AND ACUTE CARDIAC ISCHEMIA
Ioannidis et al

only the rest scan was used; a subgroup of patients in the
study by Stewart et al19 (36/68 patients) also underwent
stress scanning when the rest scan was unrevealing.
Characteristically, all studies addressed populations of
patients with low, or at most moderate, risk of AMI and
ACI, and the ECG was normal or nondiagnostic. Also,
patients with a history of AMI were often excluded to
avoid difficulty in interpreting segmental wall-motion
abnormalities. The report by Kontos et al15 included
patients regardless of a prior history of AMI, but separate
data are also provided for the subgroup of patients with-
out such a history. In this regard, these studies generally
targeted highly selected populations. In the report by
Varetto et al,22 only 64 of 274 consecutive patients with
chest pain qualified for inclusion. In the article by Tatum
et al,14 a subset of the patients in the article by Kontos et
al,15 the qualifying rate was 442 of 1187. In the report by
Stewart et al,19 the study population represented only 7%
of all patients evaluated for chest pain syndromes not
believed to be the result of AMI. Unsuccessful imaging
was uncommon in the 2 studies that provided such data
(<2% for both combined).15,16
Diagnostic performance data and pooled estimates for
the 5 qualifying studies are shown in Table 4. The overall
test performance suggests excellent sensitivity (91.5% to
100%) but only modest specificity (49.3% to 84.4%) for
AMI. Sensitivity for AMI was 100% in 3 of the 5 studies.
Because all zero values in the cells of false-negative results
must be replaced by some other nominal value to allow
pooled calculations, the pooled estimates would depend
on the imputed value. The accuracy results for ACI should
be interpreted with caution because the definitions of
coronary disease were heterogeneous. Figure 2A and 2B,
show the respective summary receiver-operating charac-
teristic curves for the diagnosis of ACI and AMI for all
studies, regardless of whether they were performed in the
ED setting.
Our meta-analysis suggests that there are still rather
limited data on the implementation of the technetium-
99m sestamibi scan in the ED setting and its diagnostic

Table 3.
Characteristics of studies of technetium-99m sestamibi imaging in the ED.

Subjects Mean Male Inclusion

Evaluated Age Sex (Exclusion) Blinding
Study (Enrolled) (y) (%) Criteria Test Criteria Performed Potential Bias

Hilton et al, 199421 102 (102) 50 No data Chest pain score ≥4 (previous Equivocal or abnormal Test No data
AMI, atypical chest pain, ECG
diagnostic of ACI, contraindi-
cation to radionuclide)
Stewart et al, 199619 68 (68) 52 54 Nondiagnostic history and physical Perfusion defect No data Only 36/46 patients with nega-
examination, normal or non- tive, indeterminate, or both
diagnostic ECG, normal enzyme rest sestamibi scan results
levels (AMI, unstable angina, underwent stress sestamibi
contraindications to adenosine imaging (12/36 positive)
use)
Kontos et al, 199715 532 (542) 55 46 Low- or moderate-risk patients Discrete perfusion defect with Outcome Included 47 patients not meeting
(high-risk patients, abnormal ECG associated wall-motion protocol guidelines; excluded
or nondiagnostic ECG, known CAD abnormality, thickening, or both 10 patients from analyses
and typical symptoms) (5 refused imaging, 5 not
interpretable)
Kontos et al, 199811 185 (186) 51 49 Low-risk (typical symptoms <30 Discrete perfusion defect with Outcome One patient with negative
min or atypical symptoms >30 associated wall-motion abnormality, perfusion imaging results was
min) or moderate-risk (symptoms thickening, or both excluded from analysis
>30 min) patients (high risk for
ACI: abnormal ECG, known CAD
and typical symptoms)
Kontos et al, 199916 620 (721) 56 47 Low- or moderate-risk patients Discrete perfusion defect with No data 101 patients excluded (3 unin-
(PTCA <6 mo, serial troponin I associated wall motion abnormality, terpretable, 71 initial troponin I
not obtained, history of CAD) thickening, or both only, 27 with preadmission
PTCA)
PTCA, Percutaneous transluminal coronary angiography.

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Table 4.
Diagnostic performance of technetium-99m sestamibi imaging in the ED.

Test Performance
Study Population Prevalence Sensitivity Specificity Study
Study Size (Setting)* of Disease (%) (%) (%) Quality†

Hilton et al, 199421 102 III ACI 14 93 79 B

AMI 12 100 78
Stewart et al, 199619 68 III ACI 9 100 53 B
AMI 1.5 100 49
Kontos et al, 199715 532‡ III ACI 17 80 81 A
AMI 5 93 71
Kontos et al, 199811 185‡ III ACI No data No data No data A
AMI 3 100 84
Kontos et al, 199916 620‡ III ACI No data No data No data A
AMI 10 92 67
Overall 1,571 III ACI 9–17 89 (73–96)§ 77 (63–87)§ A
AMI 2–12 92–100II 49–84II
*Category
III studies included patients with nondiagnostic ECGs. See accompanying synopsis article.2
†
Study quality A articles are high-quality, well documented, unbiased studies. Study quality B articles are fair quality and incompletely documented, with no evidence of significant bias. Study quality
C articles are poor quality and poorly documented, with possibly significant bias. See accompanying synopsis article.2
‡
There are some overlaps in the patient populations in these 3 reports. Communication with the author of these reports revealed that 53 patients in the 1997 Kontos et al study15 were included in the
1998 Kontos et al study,11 and approximately 55 patients in the 1997 Kontos et al study11 were included in the 1999 Kontos et al study.16
§
Results of meta-analysis (95% CI) with random-effects calculations.
IIBecause of overlaps in data reporting, meta-analysis was not performed; only range of results is shown.

Figure 2.
A, Summary receiver-operating characteristic curve analysis of technetium-99m sestamibi scanning in the diagnosis of AMI. B, Summary
receiver-operating characteristic curve analysis of technetium-99m sestamibi scanning in the diagnosis of ACI. The 3 studies by Kontos et
al11,15,16 include overlapping subjects. Only the first article15 includes data for both AMI and ACI. It is the only study by Kontos et al rep-
resented here. See Figure 1 for description.

A Sensitivity B Sensitivity
100 100
90 90

80 80

70 70

60 60

50 50

40 40

30 30
20 20

10 10

0 0
0 10 20 30 40 50 60 70 80 90 100 0 10 20 30 40 50 60 70 80 90 100
100–Specificity 100–Specificity

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IMAGING TECHNOLOGIES AND ACUTE CARDIAC ISCHEMIA
Ioannidis et al

accuracy. The test has been used in selected patient popu- 17. Weissman IA, Dickinson CZ, Dworkin HJ, et al. Cost-effectiveness of myocardial perfusion
imaging with SPECT in the emergency department evaluation of patients with unexplained chest
lations with low-to-moderate risk of AMI or ACI and no pain. Radiology. 1996;199:353-357.
diagnostic signs determined by means of ECG changes. 18. Weissman IA, Dickinson C, Dworkin H, et al. Emergency center myocardial perfusion SPECT—
The majority of the data pertain to patients without a long-term follow-up: cost effective imaging providing diagnostic and prognostic information. J
Nucl Med. 1995;36(Suppl 5):88P.
prior history of myocardial infarction. Thus, the general-
19. Stewart RE, Dickinson CZ, Weissman IA, et al. Clinical outcome of patients evaluated with
izability of the data is low, and the test may not be appro- emergency center myocardial perfusion SPET for unexplained chest pain. Nucl Med Comm.
priate beyond the studied populations. In these patients, 1996;17:459-462.
the test has excellent sensitivity for AMI and very good 20. Hilton TC, Fulmer H, Abuan T, et al. Ninety-day follow-up of patients in the emergency
department with chest pain who undergo initial single-photon emission computed tomographic
sensitivity for ACI in general. Specificity is modest, par- perfusion scintigraphy with technetium 99m-labeled sestamibi. J Nucl Cardiol. 1996;3:308-311.
ticularly for AMI. There are as of yet no studies addressing 21. Hilton TC, Thompson RC, Williams HJ, et al. Technetium-99m sestamibi myocardial perfu-
the clinical effect of using this imaging modality in the ED sion imaging in the emergency room evaluation of chest pain. J Am Coll Cardiol. 1994;23:1016-
setting. 1022.
22. Varetto T, Cantalupi D, Altieri A, et al. Emergency room technetium-99m sestamibi imaging
to rule out acute myocardial ischemic events in patients with nondiagnostic electrocardiograms.
REFERENCES J Am Coll Cardiol. 1993;22:1804-1808.
1. Selker HP, Zalenski RJ, Antman EM, et al. An evaluation of technologies for identifying
acute cardiac ischemia in the emergency department: a report from the National Heart Attack
Alert Program Working Group. Ann Emerg Med. 1997;29:13-87.
2. Lau J, Ioannidis JPA, Balk EM, et al. Diagnosing acute cardiac ischemia in the emergency
department: a systematic review of the accuracy and clinical effect of current technologies. Ann
Emerg Med. 2001;37:453-460.
3. Horowitz RS, Morganroth J, Parrotto C, et al. Immediate diagnosis of acute myocardial
infarction by two-dimensional echocardiography. Circulation. 1982;65:323-329.
4. Sasaki H, Charuzi Y, Beeder C, et al. Utility of echocardiography for the early assessment of
patients with nondiagnostic chest pain. Am Heart J. 1986;112:494-497.
5. Peels CH, Visser CA, Kupper AJ, et al. Usefulness of two-dimensional echocardiography for
immediate detection of myocardial ischemia in the emergency room. Am J Cardiol. 1990;65:687-691.
6. Sabia P, Afrookteh A, Touchstone DA, et al. Value of regional wall motion abnormality in
the emergency room diagnosis of acute myocardial infarction. A prospective study using two-
dimensional echocardiography. Circulation. 1991;84(Suppl 3):I85-I92.
7. Levitt MA, Promes SB, Bullock S, et al. Combined cardiac marker approach with adjunct
two-dimensional echocardiography to diagnose acute myocardial infarction in the emergency
department. Ann Emerg Med. 1996;27:1-7.
8. Mohler ER III, Ryan T, Segar DS, et al. Comparison of digital with videotape echocardiogra-
phy in patients with chest pain in the emergency department. J Am Soc Echocardiogr.
1996;9:501-7.
9. Trippi JA, Kopp G, Lee KS, et al. The feasibility of dobutamine stress echocardiography in the
emergency department with telemedicine interpretation. J Am Soc Echocardiogr. 1996;9:113-116.
10. Trippi JA, Lee KS, Kopp G, et al. Dobutamine stress tele-echocardiography for evaluation of
emergency department patients with chest pain. J Am Coll Cardiol. 1997;30:627-632.
11. Kontos MC, Arrowood JA, Jesse RL, et al. Comparison between 2-dimensional echocardio-
graphy and myocardial perfusion imaging in the emergency department in patients with possible
myocardial ischemia. Am Heart J. 1998;136:724-733.
12. Mohler ER III, Ryan T, Segar DS, et al. Clinical utility of troponin T levels and echocardiog-
raphy in the emergency department. Am Heart J. 1998;135:253-260.
13. Gibler WB, Runyon JP, Levy RC, et al. A rapid diagnostic and treatment center for patients
with chest pain in the emergency department. Ann Emerg Med. 1995;25:1-8.
14. Tatum JL, Jesse RL, Kontos MC, et al. Comprehensive strategy for the evaluation and triage
of the chest pain patient. Ann Emerg Med. 1997;29:116-125.
15. Kontos MC, Anderson FP, Hanbury CM, et al. Use of the combination of myoglobin and CK-
MB mass for the rapid diagnosis of acute myocardial infarction. Am J Emerg Med. 1997;15:14-
19.
16. Kontos MC, Anderson FP, Schmidt KA, et al. Early diagnosis of acute myocardial infarction
in patients without ST-segment elevation. Am J Cardiol. 1999;83:155-158.

MAY 2001 37:5 ANNALS OF EMERGENCY MEDICINE 4 7 7