Myocardial infarction: absence of 5 presenting complaints helped rule out a myocardial infarction

Clinical bottom line (level 4)

  1. One in 130 patients attending an emergency department had a myocardial infarction.
  2. Patients who presented to an emergency department with chest pain, tachycardia, dyspnoea, syncope or weakness were more likely to have an acute myocardial infarction (LR + 10) .
  3. Patients without these symptoms were less likely to have a myocardial infarction (LR - 0.068) .
Graff et al: Ann Emerg Med 2001; 36 : 554-560
Expires January 2004

The study

Setting: emergency department, acute hospital, USA

18759 patients attending an emergency department

?independent ?blinded reference standard, applied in all patients from a consecutive appropriate spectrum.
Reference standard:
  • final diagnosis on discharge from emergency department
Diagnostic test: patient's chief complaint on arrival in emergency department
  • Validation of a clinical prediction rule derived from 22717 patients attending the same emergency department.
  • ECG ordered if patient's chief complaint was any of the following
    • chest pain
    • rapid heart beat
    • weakness
    • syncope
    • short of breath

The evidence

pre-test probability of acute myocardial infarction: 0.76% (95% CI: 0.63% to 0.88%)

diagnostic test myocardial infarction no myocardial infarction LR+
(95% CI)		 post-test probability LR-
(95% CI)		 post-test probability
relevant chief complaint 133 1247 14
(13 to 15) 		10% 0.068
(0.036 to 0.13) 		0.052%
total 142 18617

Comments

  1. Unclear if reference standard independent or blinded since based on discharge ICD-9 coding.

Citation

  1. Graff L, Palmer AC, LaMonica P, et al: triage of patients for a rapid (5-minute) electrocardiogram: a rule based on presenting chief complaints. Ann Emerg Med 2001; 36 : 554-560
Search Terms: from ACP Journal Club other articles noted
Contributor: Chris Ball, January 2002
Reviewer:

Clinical Question.
Patient attending emergency department
Intervention or Exposure presenting complaint
Outcome myocardial infarction