Source Document: Marsan et al. Evaluation of a Clinical Decision Rule for Young Adult Patients with Chest Pain. Acad Emerg Med. 2005; 12(1): 24-31 (n=593). Walker et al. Characteristics and Outcomes of Young Adults Who Present to the Emergency Department with Chest Pain. Acad Emerg Med. 2001; 8(7): 703-708 (n=312). Lee TH et al. Long-term survival of emergency department patients with acute chest pain. Am J Cardiol. 1992; 69:145–51 (n=333).
Narrative: Heart disease remains a major cause of death in western industrialized nations and around the world. Health care providers have traditionally found it difficult to reliably forecast which patients with vague or 'soft' symptoms of possible heart disease will actually have a heart problem. Chest pain that is not reproducible with exertion, and that is not occurring in the setting of electrocardiogram changes that are typical of active heart disease, is one such 'soft' symptom.
It is clear that a small proportion of these patients will suffer a heart attack or even a death, but reliably forecasting these outcomes without over-treating an unacceptable proportion has proved impossible with current technologies and decision aids. This review examines the highest quality data available from emergency department evaluation of patients under the age of 40 who do not have classic cardiac pain, nor classic EKG abnormalities, and who do not have a history of known heart problems. When an emergency physician judged the patient unlikely to have a coronary syndrome and the above criteria were present, the chance of a heart attack or death was extremely small, roughly 1 in 500. In these data there was one death that occurred within 30 days of the initial evaluation, and this occurred in a patient with metastatic cancer. It was unclear if the death was related to heart disease. For conservative purposes this death was counted as potentially cardiac in nature.
Caveats: These data rely on physician judgment which is generally unstructured, and it is likely that there is considerable variation in judgment patterns. The data are from multiple centers though one center disproportionately contributes, and that is an urban ED in Philadelphia where chest pain studies are of unusually high quality with uncommonly complete data collection and 30-day follow-up success. This population may exhibit different characteristics than some others, however the sociodemographic profile of this population (low socio-economic status, high minority) would suggest a higher-than-average risk profile rather than a diminished risk profile.
Importantly, because there is no evidence that percutaneous coronary intervention is beneficial outside of emergent use during ST-elevation myocardial infarction (major heart attack), and only weak evidence of a long term benefit with bypass surgery, we do not count 'revascularization' as an important outcome. In these data, however, there were no reported revascularization procedures.
Author: David Newman, MD
Published/Updated: September 19, 2010
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