Chest pain: echocardiography helped indicate patients at increased risk of dying.

Clinical bottom line (level 1b)

  1. One in five patients presenting to the emergency department with acute chest pain were dead within 2.5 years.
  2. The risk of dying was increased if any of the following were present on echocardiography
    • severe left ventricular dysfunction
    • moderate-to-severe mitral regurgitation
Fleischmann et al: Journal of the American College of Cardiology 1994; 23 (6): 1390-1396
Expires February 2002

The study

Prospective cohort study with objective outcomes, adjusted for confounding factors, not validated in an independent set of patients.

Setting: emergency department, university hospital, USA

513 patients (aged mean 62, 53% female) presenting with acute chest pain, whose physician referred them for an echocardiogram within 1 month

Excluded if
  • aged <30 years
  • chest pain due to trauma or a reason visible on chest X-ray



    • Factors studied:
  • age, history of ischaemic heart disease, ischaemic changes on emergency ECG, presence of heart failure, left ventricular function or hypertrophy, regional wall motion abnormalities, valvular disease
  • severe left ventricular dysfunction (ejection fraction < 30%)
  • moderate to severe mitral regurgitation




    • A Cox regression analysis was used to adjust for confounding factors

    87% followed for at least 1 year: mean 2.5 years
    Outcomes studied:
  • death

    • The evidence

    outcome time to outcome number of patients/total number %
    (95% CI)    		 NNF
    (95% CI)
    death at least 1 year: mean 2.5 years 102/513 20%
    (16% to 23%)    		 5
    (4 to 6)

    prognostic factor for
    death     		time to outcome adjusted RR
    (95% CI)    		 NNF+
    (95% CI)
    severe left ventricular dysfunction at least 1 year: mean 2.5 years 3.8
    (1.9 to 7.5)     		2
    (1 to 6)
    moderate to severe mitral regurgitation at least 1 year: mean 2.5 years 2.4
    (1.5 to 3.7)     		4
    (2 to 10)

    Comments

    1. Since these patients were referred by their physician, they are not a truely representative sample of the total population - specifically they were older, and had more risk factors for ischaemic heart disease.

    Citation

    1. Fleischmann KE, Goldman L, Robiolio PA, et al: Echocardiographic correlates of survival in patients with chest pain. Journal of the American College of Cardiology 1994; 23 (6): 1390-1396
    Search Terms: reference from review article
    Contributor: Chris Ball and Clare Wotton, February 2000
    Reviewer:

    Clinical Question.
    Patient chest pain
    Intervention or Exposure echocardiography
    Outcome death