Prognostic significance of interleukin-6 measurement in the diagnosis of acute myocardial infarction in emergency department

BACKGROUND: Markers of inflammation may predict both coronary artery disease (CAD) and adverse outcomes in patients with known CAD. Here, we investigated the role of interleukin-6 (IL-6) in the "triage" and risk assessment of patients admitted to emergency department (ED). METHODS: Serum IL-6 and high sensitivity C-reactive protein (hs-CRP) levels were prospectively evaluated in 88 patients with a history of precordial chest pain or shortness of breath of recent onset (<6 h). RESULTS: Of the 88 patients, 21% were discharged from the ED with diagnosis of non-ischemic chest pain (NICP), 39% had a final diagnosis of unstable angina (UA) and 40% experienced an acute myocardial infarction (AMI). Median IL-6 (p<0.001) and hs-CRP (p<0.01) levels on admission were significantly increased in patients with AMI compared with patients with NICP or UA. IL-6 levels correlated with hs-CRP (p<0.01). Multivariate analyses including known risk factors showed that elevated creatine kinase-MB (p<0.05) and IL-6 levels (p<0.01) were independently associated with a final diagnosis of AMI. Elevated IL-6 levels significantly predicted the risk of AMI (OR=2.47, p=0.006) in chest pain-enzyme negative patients. CONCLUSIONS: IL-6 may behave as an adjunctive diagnostic tool to assist in the risk assessment of enzyme-negative patients with precordial chest pain of recent onset.     

Adverse outcomes following emergency department discharge of patients with possible acute coronary syndrome

Objective: To determine the proportion of adverse events in patients discharged after ED assessment for possible acute coronary syndrome. Methods: Prospective observational cohort study enrolling consecutive patients presenting with symptoms suggestive of coronary syndrome. Main outcome was the proportion of adverse coronary events (defined a priori) within 30 days. Results: Of 2627 patients, 1819 (69%) were discharged without a diagnosis of coronary syndrome and 808 (31%) were admitted for further investigation and treatment. Of these, 385 (14.7%) were given a final diagnosis of acute coronary syndrome. On 30 day follow up, 18 of the discharged patients were diagnosed with acute coronary syndrome (0.7%; 95% confidence intervals [CI] 0.4–1.1%), 10 with unstable angina (0.4%; 95% CI 0.2–0.7%) and 8 with non‐ST elevation myocardial infarction (0.3%; 95% CI 0.2–0.6%). There were no cases of ST elevation infarction or death. The sensitivity for diagnosis of acute coronary syndromes was 95.5% (95% CI 92.9–97.3%). Average length of stay was 7 h for discharged patients. Forty‐six per cent of patients with diabetes and 47% with a past history of coronary disease were discharged. Subsequent outpatient stress testing was performed in 13.6%. Conclusions: In a large Australian ED, less than 1% of patients presenting with symptoms suggestive of coronary syndrome were discharged and subsequently had a 30 day adverse event. Reducing this proportion by admitting patients with traditional risk factors would markedly increase hospital workload. Opportunities exist to improve both the safety and efficiency of chest pain assessment in the ED.     

Chest pain unit management of patients at low and not low-risk for coronary artery disease in the emergency department. A 5-year experience in the Florence area.

In this study, we screened a total of 6723 consecutive patients with chest pain and ECG non-diagnostic for acute myocardial infarction (AMI) on presentation to the emergency department (ED). The aim of the study was to avoid missed AMI, improve safe early discharge and reduce inappropriate coronary care unit (CCU) admission. Chest pain patients were triaged using a clinical chest pain score and managed in a chest pain unit (CPU). Patients with a low clinical chest pain score were considered at very 'low-risk' for cardiovascular events and discharged from the ED; patients with a high chest pain score were submitted to CPU management. Observation and titration of serum markers of myocardial injury were obtained up to 6 hours. Rest or stress myocardial scintigraphy (SPECT) was performed in patients > 40 years or with > or = 2 major coronary risk factors. Exercise Tolerance Test (ETT) or Stress-Echocardiogram (stress-Echo) were performed in younger patients or with < 2 coronary risk factor, or unable to exercise, respectively We discharged directly from the ED the majority of patients (4454; 66%): in this group there was only a 0.2% final diagnosis of coronary artery disease (CAD) at follow-up. The remaining 34% of patients, with non-diagnostic or normal ECG, were managed in the CPU. In this group, 1487 patients (representing 22% of the overall study group) were found positive for CAD, two-thirds because of delayed ECG or serum markers of myocardial injury, and one-third by Echo, SPECT or ETT. In conclusion, CPU based management allowed 22% early detection of myocardial ischaemia and 78% early discharge from the ED avoiding inappropriate CCU admission and optimizing the use of urgent angiography.     

Stress testing before discharge is not required for patients with low and intermediate risk of acute coronary syndrome after emergency department short stay assessment

Objective: To investigate the usefulness of stress testing before discharge in patients assessed low to intermediate risk of acute coronary syndrome (ACS). Methods: A prospective observational study was undertaken of patients presenting to the ED with suspected myocardial ischaemia. After negative initial electrocardiogram (ECG) and serum troponin testing, patients were admitted to the emergency short stay unit (ESSU) for further evaluation using a chest pain protocol that included stress testing as the final risk stratification tool. The primary outcome measure was evidence of myocardial ischaemia at stress testing. Results: Of the 300 patients enrolled and followed up, there were no deaths at 30 days and no myocardial infarcts in patients discharged from the short stay. Two patients (0.67%) had positive serum troponin levels at 6 h after the onset of chest pain and were diagnosed with non‐ST segment elevation myocardial infarctions. Three patients (1%) had abnormal stress testing and were admitted to hospital from ESSU. On review, all three patients were high risk, according to The National Heart Foundation of Australia/Cardiac Society of Australia and New Zealand guidelines. Conclusion: The present study showed that an ED short stay unit can effectively evaluate and manage patients with low and intermediate risk of ACS. The study suggests that patients with low and intermediate risk for ACS might safely be discharged after normal serial ECG and cardiac biomarkers, with a view to early outpatient stress testing. With strict adherence to admission criteria, there does not appear to be any benefit of stress testing before discharge.     

Emergency Department CK-MB: A Predictor of Ischemic Complications

ABSTRACT
Objective : To demonstrate that a positive CK-MB in the emergency department (ED) predicts an increased risk for complications of myocar-dial ischemia in patients admitted to the hospital for evaluation of chest pain.
Methods : 53 academic and community hospital EDs participated in this prospective observational cohort analysis of 5,120 patients with chest pain without ST-segment elevation on the initial ED 12-lead electrocardiogram. All patients were admitted for evaluation of chest pain in one of the participating hospitals as part of the National Cooperative CK-MB Project. Patients were stratified by whether or not they had an elevated CK-MB level in the ED. CK-MB measurements were made on ED presentation and two hours later. Patient medical records were reviewed for inpatient diagnoses—myocardial infarction (MI) or other diagnosis —and for ischemic complications—cardiac-related death, recurrent or delayed in-hos-pital MI, significant ventricular arrhythmias, new conduction defects, congestive heart failure, and cardiogenic shock.
Results : 369 (7.2%) of the 5,120 patients had MI. The proportion of patients with any complication in the MI group was 24%, while the complication rate in the non-MI group was 0.4%. In all patients, regardless of final diagnosis, the relative risk of any complication was 16.1 (95% CI 11.0–23.6) in those with a positive ED CK-MB versus negative ED CK-MB patients. Similarly, the relative risk of death was 25.4 (95% CI 10.8— 60.2) in positive ED CK-MB versus negative ED CK-MB patients.
Conclusions : Multicenter data support the hypothesis that CK-MB measurements can help risk-stratify ED chest pain patients whose initial ECGs are without diagnostic ST-segment elevation.     

The use of exercise stress testing for the management of low-risk patients with chest pain

Objective

This retrospective study assessed the contribution of exercise stress testing (EST) in the evaluation of patients with low risk for coronary heart disease who presented to the emergency department (ED) with chest pain.

Basic Procedures

The study included 175 patients who presented to the ED with chest pain and underwent EST between January 1, 2005, and November 30, 2006.

Main Findings

After the EST, 113 patients were discharged, and 62 were admitted. Exercise stress testing's positive predictive value for coronary artery disease among admitted patients was 35.7%, and sensitivity was 95.2%.Exercise stress testing's negative predictive value among discharged patients was 99.1%. None of the 113 discharged patients returned to the ED for cardiac reasons during the 30-day follow-up period.

Principal Conclusion

A chest pain unit or a parallel facility for evaluating patients with chest pain and with low risk for active coronary disease is necessary for detecting low-risk patients who eventually need cardiac intervention.     

Best Clinical Practice: Current Controversies in the Evaluation of Low-Risk Chest Pain with Risk Stratification Aids. Part 2

Background

Chest pain accounts for 10% of emergency department (ED) visits annually, and many of these patients are admitted because of potentially life-threatening conditions. A substantial percentage of patients with chest pain are at low risk for a major cardiac adverse event (MACE).

Prospective validation of Thrombolysis in Myocardial Infarction and front door Thrombolysis in Myocardial Infarction risk scores in Chinese patients presenting to the ED with chest pain

Background

Chest pain is a common complaint among emergency department (ED) patients. The Thrombolysis in Myocardial Infarction (TIMI) and front door TIMI (FDTIMI) scores are used to risk stratify chest pain patients in many Western countries; they have not been validated in patients with undifferentiated chest pain in Asia. Our objective was to establish the relationship between the TIMI and FDTIMI scores and the 30 day rate of major adverse cardiac outcomes (MACE) in Chinese patients presenting to the ED with chest pain.

Methods

Prospective, single-center, observational cohort study of consecutive patients presenting with chest pain from July 2009 until March 2010 to a Hong Kong university hospital ED. Data collected included patient characteristics, TIMI items and past medical and medication history. Primary outcome was MACE within 30 days of presentation. MACE was a composite outcome of any of the following: death (all causes), readmission with myocardial infarction, acute coronary syndrome not diagnosed at initial ED presentation and coronary revascularization.

Results

One thousand patients recruited with complete 30-day follow-up. STEMI patients (n = 75) were excluded. Mean patient age 66.8 ± 13.9 years; 51.7% male. 119 (12.9%) patients had MACE within 30 days of presentation. The incidence of MACE ranged from 0 for TIMI0 to 37.5% for patients with TIMI6/7. Increasing TIMI and FDTIMI scores were associated with a higher incidence of MACE.

Conclusions

This validation suggests that the TIMI/FDTIMI scores can be employed in Hong Kong Chinese; they may be useful for risk stratification of Chinese ED patients with undifferentiated chest pain elsewhere.     

Differences between Chest Pain Observation Service Patients and Admitted "Rule-out Myocardial Infarction" Patients

Objective: To compare and contrast the patient characteristics of ED patients at low risk for acute cardiac ischemia who were assigned to a chest pain observation service vs those admitted to a monitored inpatient bed for "rule-out acute myocardial infarction" (R/O MI).
Methods: This was a retrospective, cross-sectional comparison of adult patients considered at relatively low risk for cardiac ischemia and who were evaluated in 1 of 2 settings: a short-term observation service and an inpatient monitored bed. All patients had an ED final diagnosis of "chest pain," "R/O MI," or "unstable angina" during the 7-month study period. Demographic features and presenting clinical features were examined as a function of site of patient evaluation.
Results: Of 531 study patients, 265 (50%) were assigned to the observation service. Younger age (OR = 1.75, 95% CI 1.26, 2.44, for each decrement of 20 years), the complaint of "chest pain" (OR = 2.35, 95% CI 1.34, 4.12), and the absence of prior known coronary artery disease (OR = 1.64, 95% CI 1.13, 2.38) were the principal independent factors associated with assignment to a chest pain observation service bed. Conclusions: Patients evaluated in a chest pain observation service appear to have different clinical characteristics than other individuals admitted to a monitored inpatient bed for "R/O MI." Investigators should address differences in clinical characteristics when making outcome comparisons between these 2 patient groups.     

The utility of the presence or absence of chest pain in patients with suspected acute myocardial infarction

In 422 patients admitted from the emergency department (ED) for suspected acute myocardial infarction, the hypothesis that chest pain that persists on arrival in the ED or recurs during the initial ED evaluation is a useful predictor of acute myocardial infarction (AMI) and complications of coronary ischemia was tested. Compared with patients whose chest pain spontaneously ceased before arrival in the ED, patients whose chest pain persisted or recurred during the initial ED evaluation had a 2.3 times greater risk of interventions (P less than .001), a 1.7 times greater risk of complications (P = .045), a 3.8 times greater risk of life-threatening complications (P = .04), and a 2.4 times greater risk of AMI (P = .005). A third group of patients with suspected AMI never experienced chest pain. This group of patients who never experienced chest pain had a three times higher risk of death (P = .02) compared with patients whose chest pain persisted or recurred in the ED, and a 2.1 times greater risk of intervention (P = .01), a 5.2 times greater risk of life-threatening complication (P = .015), and a 7.9 times greater risk of death (P = .025) compared with patients whose chest pain resolved before arrival in the ED. It was concluded that patients with chest pain that resolves spontaneously before arrival to the ED have a better in-hospital prognosis than any other group.     

Beyond the Twelve-Lead Electrocardiogram: Diagnostic Tests in the Evaluation for Suspected Acute Myocardial Infarction in the Emergency Department,Part II

On a daily basis the emergency physician is faced with the difficult task of determining whether or not a patient with acute chest pain is sustaining an acute myocardial infarction. In most cases this is not a straightforward decision. Although observation units are being used more often for chest pain evaluations, many emergency physicians currently admit such patients to an intensive care setting. Because fewer than one-third of emergency department chest pain patients actually suffer an acute myocardial infarction, expensive resources are, in retrospect, used unnecessarily. Conversely, patients who are infarcting, and are inadvertently discharged home from the emergency department, have a worse prognosis than those admitted. This two-part series reviews the newer modalities available that may help the emergency physician arrive at a more accurate diagnosis. This article, Part II, will review the use of biochemical assays of cardiac proteins and discuss the Chest Pain Observation Unit.     

Clinical features of patients inappropriately undiagnosed of pulmonary embolism

PurposesThe objective of this study was to identify clinical factors associated with delayed diagnosis of acute pulmonary embolism (PE) in the emergency department (ED).Basic proceduresA retrospective observational study was performed at three University affiliated Hospitals; 436 consecutive patients who presented to the ED with an acute PE confirmed by chest computed tomography from 2008 to 2011 were included. Patients were divided into 3 groups: group 1, PE was diagnosed while the patient was still in the ED; group 2, PE was diagnosed during hospitalization; group 3, patients who were sent home with a wrong alternative diagnosis and returned to the ED and were diagnosed of PE.Main findingsOne hundred forty-six patients (33.5%) had a delayed diagnosis of PE—21.5% belong to group 2 and 11.9% to Group 3. Chronic coexisting medical conditions like asthma or chronic obstructive pulmonary disease were independent predictors of a delayed diagnosis in patients who were admitted to hospital whereas non-specific and less severe symptoms like the presence of pleuro-mechanic thoracic pain, fever, hemoptysis, or the presence of a pulmonary infiltrate in chest x-ray were independent predictors of a delayed diagnosis in patients who were sent home.Principal conclusionsDelay in diagnosis of acute PE is frequent despite current diagnostic strategies. Patients are sent home or admitted to hospital with a wrong diagnosis depending on clinical presentation or coexisting medical conditions.     

Gender differences in reported symptoms for acute myocardial infarction: Impact on prehospital delay time interval

A retrospective observational study using database registry of consecutive patients admitted to 16 King County hospital Coronary Care Units (CCU) was conducted to assess gender differences in symptom presentation for acute myocardial infarction (AMI) and investigate how symptom presentation relates to prehospital delay time interval from acute symptom onset to emergency department (ED) presentation. Between January 1991 and February 1993, 4,497 patients were admitted to the CCUs with diagnosed AMI. Accredited record technicians abstracted age, gender, race, transport method, symptom presentation (chest pain, sweating, nausea, shortness of breath, epigastric pain, and fainting), delay time interval between acute symptom onset and presentation to hospital ED, and discharge diagnosis from the patients' medical records. After adjusting for age and history of diabetes, no gender differences remained for frequencies of chest pain, fainting, or epigastric pain. Women reported more nausea and shortness of breath but less sweating than men as symptoms of AMI. Chest pain, sweating, and fainting were associated with decreasing delay time intervals. Age, gender, histories of AMI and diabetes, and transport choice were also significantly related to delay time interval. These results show that gender differences occur in AMI symptom experience. However, how symptoms relate to the gender gap in delay time interval is not clear. These findings suggest that health care professionals need to tailor information about possible symptoms of AMI to the patient's gender, age, and medical history.     

Relationship between a Clear-cut Alternative Noncardiac Diagnosis and 30-day Outcome in Emergency Department Patients with Chest Pain

Background: Accurate identification of patients with acute coronary syndromes (ACSs) in the emergency department (ED) remains problematic. Studies have not been able to identify a cohort of patients that are safe for immediate ED discharge; however, prior studies have not examined the utility of a clear‐cut alternative noncardiac diagnosis. Objectives: To compare the 30‐day event rate in ED chest pain patients who were diagnosed with a clear‐cut alternative noncardiac diagnosis with the 30‐day event rate in the cohort of patients in whom a definitive diagnosis could not be made in the ED. Methods: This was a prospective cohort study of consecutive ED patients with potential ACS. Data included demographics, medical and cardiac history, laboratory and electrocardiogram results, and whether or not the treating physician ascribed the condition to a clear‐cut alternative noncardiac diagnosis. The main outcome was death, acute myocardial infarction (AMI), or revascularization within 30 days, as determined by phone follow‐up or medical record review. Results: The investigators enrolled 1,995 patients in the ED who had potential ACSs. Overall, 77 had a final hospital diagnosis of AMI (4%). Within 30 days, 73 patients received revascularization (4%), and 26 died (1%). There were 599 (30%) patients given a clear‐cut alternative noncardiac diagnosis. Comparing the patients with a clear‐cut alternative noncardiac diagnosis with those without an obvious noncardiac diagnosis, the presence of a clear‐cut alternative noncardiac diagnosis was associated with a reduced risk of an in‐hospital triple‐composite endpoint (death, MI, and revascularization), with a risk ratio of 0.32 (95% confidence interval [CI] = 0.19 to 0.55) and 30‐day triple‐composite endpoint with a risk ratio of 0.45 (95% CI = 0.29 to 0.69); however, patients with a clear‐cut alternative noncardiac diagnosis still had a 4% event rate at 30 days (95% CI = 2.4% to 5.6%). Conclusions: In the ED chest pain patient, the presence of a clear‐cut alternative noncardiac diagnosis reduces the likelihood of a composite outcome of death and cardiovascular events within 30 days. However, it does not reduce the event rate to an acceptable level to allow ED discharge of these patients.     

Prevalence of acute myocardial infarction and other serious diagnoses in patients presenting to an urban emergency department with chest pain

A retrospective cohort study and chart review were performed to estimate the absolute and relative prevalence of the serious diagnoses that might cause a patient to present to the Emergency Department (ED) with a chief complaint of chest pain. In this study, we queried a database of 347,229 complete visits to the San Francisco General Hospital Emergency Department between July 1, 1993 and June 30, 1998 for visits by patients > 35 years old with a chief complaint of chest pain and no history of trauma. Visits for chest pain that resulted in hospitalization were assigned to one of nine diagnostic groups according to final diagnoses as coded in the database. Manual chart review by trained abstractors using explicit criteria was done when group assignment based on coded diagnoses was unclear and in all diagnoses of pulmonary embolism and aortic dissection. Of 8711 visits (2.5% of all visits) with a chief complaint of non-traumatic chest pain, 3271 (37.6%) resulted in hospitalization. Of the 3078 (94.1% of those hospitalized) assigned a final diagnosis, 329 (10.7% of hospitalizations, 3.8% of all visits) had acute myocardial infarction, 693 (22.5%) had either unstable angina or stable coronary artery disease, and 345 (11.2%) had pulmonary causes (mainly bacterial pneumonia) deemed serious enough to require hospitalization. Pulmonary embolism and aortic dissection were diagnosed in only 12 (0.4%) and 8 (0.3%) patients, respectively. In 905 (29.4%) hospitalizations for chest pain, myocardial infarction was “ruled out” and no cardiac ischemia or other serious etiology for the chest pain was diagnosed. Among patients presenting with chest pain, those in older age groups had dramatically increased risk of acute myocardial infarction. Women presenting with chest pain had a lower risk of acute myocardial infarction than men. In conclusion, the prevalence of acute myocardial infarction in the undifferentiated ED patient with a chief complaint of chest pain is only about 4%. An equal number of patients will have a serious pulmonary cause as the etiology of their pain. Pulmonary embolism and aortic dissection are important but extremely rare causes of a chest pain presentation to the ED.     

It is safe to manage selected patients with acute coronary syndromes in unmonitored beds

This prospective, observational study evaluated the safety of the Western Hospital admission protocol for patients with suspected acute coronary syndromes. The study included all patients admitted from the Emergency Department with an admission diagnosis of unstable angina, post infarct angina, atypical chest pain, or chest pain for evaluation. Data collected included demographic data, admission diagnosis, location of admission (bed with or without cardiac monitoring), past medical history and presenting chest pain history to determine Agency for Health Care Policy (AHCPR) and Western Hospital (WH) protocol classifications, cardiac enzyme assays, electrocardiogram analysis, adverse outcomes [death, myocardial infarction (MI), dysrhythmia, acute pulmonary edema, recurrent pain], diagnosis at hospital discharge, and length of stay-(LOS). There were 508 patients with a mean age of 63.7 years enrolled in the study. Three hundred nineteen (62.8%) were admitted to beds without any cardiac monitoring. There was one unexpected death in the unmonitored group, an 85 year-old patient who suffered a presumed dysrhythmia and whom the treating physician had decided was not for resuscitation. Twelve patients suffered nonfatal MI, and none suffered pulmonary edema. All MI patients made an uneventful recovery, and none required thrombolysis. If all patients had been admitted to an area of care based on AHCPR guidelines, an additional 310 admissions to monitored beds would have been required. The results of this study suggest that selected patients with suspected acute coronary syndromes can be safely managed in beds without continuous cardiac monitoring.     

Application of the TIMI risk score in ED patients with cocaine-associated chest pain

Objective

The TIMI risk score has been validated as a risk stratification tool in emergency department (ED) patients with potential acute coronary syndrome. The goal of this study was to assess its ability to predict adverse cardiovascular outcomes in cocaine-associated chest pain.

Methods

This was a prospective cohort study of ED patients with chest pain with cocaine use. Data included demographics, medical history, and TIMI risk score. The main outcomes were acute myocardial infarction, revascularization, or death within 30 days of ED presentation.

Results

There were 261 patient visits. Patients were 43.2+8 years old, 73% male, 92% black, and 75% smokers. There were 33 patients with the composite outcome. The incidence of 30-day outcomes according to TIMI score is as follows: TIMI 0, 3.7% (95% CI, 0.1-8.3); TIMI 1, 13.2% (5.7-20.7); TIMI 2, 17.1% (4.3-29.8); TIMI 3, 21.4% (4.4-38.4); TIMI 4, 20.0% (0.1-43.6); TIMI 5/6, 50.0% (0.1-100).

Conclusions

The TIMI risk score has no clinically useful predictive value in patients with cocaine-associated chest pain.     

Characteristics and outcome for patients with acute chest pain in relation to whether or not they were transported by ambulance.

The aim of this study was to describe the characteristics and long-term outcome for patients suffering from acute chest pain in relation to whether or not they were transported to hospital by ambulance. All patients with acute chest pain who were admitted over a 21-month period to the emergency department at Sahlgrenska Hospital in G?teborg with symptoms of acute chest pain were included in the study. Consecutive patients were prospectively registered and followed with regard to mortality and morbidity over 5 years. In all, 4270 patients took part in the evaluation, of whom 1445 (34%) were transported by ambulance. Patients transported by ambulance were older (p < 0.0001) and had a higher prevalence of previous myocardial infarction, angina pectoris, hypertension, diabetes mellitus, and congestive heart failure (p < 0.0001 for all) than the others. They more frequently developed acute myocardial infarction (28% vs. 11%; p < 0.0001) and there was a final diagnosis of either confirmed or possible myocardial infarction/ischaemia in 69% compared with 38% for patients not transported by ambulance (p < 0.0001). The 5-year mortality among ambulance-transported patients was 41% vs. 16% among those who were not (p < 0.0001). When correcting for dissimilarities at baseline including final diagnosis the adjusted risk ratio for death among ambulance transported patients was 1.44 (95% confidence limit 1.26-1.65). However, we did not correct for severe non-cardiac diseases. It is concluded that among patients admitted to the emergency department with acute chest pain, those transported by ambulance had a much higher mortality during the subsequent 5 years than those who were not transported by ambulance. This was not entirely explained by observed differences at baseline. This information should be considered when ambulance organizations are being constructed.     

Impact of a chest pain clinic on recurrency of symptoms and readmissions among patients early discharged from hospital after acute myocardial infarction was ruled out.

This paper evaluates the impact of an early revisit including symptom evaluation and an exercise electrocardiogram on recurrency of symptoms and readmissions during 1 year of follow-up among patients coming to hospital with chest pain or an initial suspicion of acute myocardial infarction (AMI) but in whom the suspicion was quickly ruled out. Patients below the age of 65 admitted to the emergency department (ED) at Sahlgrenska Hospital due to chest pain or other symptoms raising a suspicion of AMI who were either directly discharged from the ED or discharged within 1 day after having AMI ruled out. Patients were allocated to two groups: (1) patients being re-evaluated in a chest pain clinic less than a week after discharge from hospital (intervention group) and (2) patients handled routinely with no formalized follow-up (control group). The intervention group (n=484) and the control group (n=374) were comparable at baseline. During 1 year of follow-up, patients in the intervention group had a lower rate of readmissions to the ED than patients in the control group (17.4% versus 24.9%, p < 0.05) and a lower rate of rehospitalizations (15.9% versus 23.3%, p < 0.05). The proportion of patients being on sick leave at any time during the follow-up did not differ and neither did the recurrency of symptoms. The introduction of a chest pain clinic for patients early discharged from hospital after having AMI ruled out indicated beneficiency in terms of a lower rate of readmissions to the ED and a lower requirement of rehospitalizations. However, a methodological weakness in the randomization procedure suggest carefulness in interpretation.