Evidence-based On-call

internal medicine

Chest pain

Causes
Clinical features
Investigations
Therapy
Prognosis

Prognosis

Be cautious about discharging patients even with a low chance of a myocardial infarction

^b

Many patients die in the next few years ^a

The risk of dying is increased with

increasing age ^a
male sex ^a
cardiovascular risk factors ^a
- smoker
- diabetes mellitus
- hypertension
history of myocardial infarction ^a
heart failure ^a
low blood pressure ^b
moderate to severe mitral regurgitation ^a
a third heart sound ^b
ECG changes ^a
an elevated CK-MB or troponin ^a

Use the following clinical prediction rule, to rank your patient for risk of dying.

^a

Sum the following:

duration of exercise in minutes
minus (5 x maximal net ST-segment deviation during or after exercise, mm)
minus (4 x treadmill angina index)

Treadmill angina index

Angina during stress test	score
no angina during exercise	0
non-limiting angina	1
stopped due to angina	2

Exercise ECG score

Total score	risk of dying
<-10	high
-10 to 4	moderate
5 or more	low

Expiry date: June 2003
Levels of Evidence used in grading these guides

Author	CM Ball
Reviewer	S Straus
CAT Writers	CJ Wotton , CM Ball , N Shenker , RS Phillips