The incorrect diagnosis of chest pain in the accident and emergency department has medical and medico-legal implications. Yet no combination of clinical factors is a reliable indicator of acute coronary heart disease. This study was designed to evaluate the diagnostic accuracy of history taking, physical examination, initial ECG changes and clinical judgement in the identification of acute coronary heart disease in accident and emergency. Four hundred and 51 successive patients presented to accident and emergency with a complaint of chest pain over a six month period. Two hundred and thirty six (52.3%) were admitted (142 males; 94 females) and 215 (47.7%) were discharged (128 males, 87 females). One hundred and seven (45%) of those admitted had confirmed acute coronary heart disease, and a further 55 (23%) had presumed acute attacks, unconfirmed by ECG and/or enzyme changes. The remaining 74 (32%) had no evidence of an acute coronary episode. Two cases who were discharged from accident and emergency were deemed to have an acute myocardial infarction but both refused admission. A further 25 patients were discharged with stable angina of effort. All 27 cases were well at the six months follow-up. Four cases discharged from accident and emergency with non-cardiac diagnoses suffered myocardial infarction within six months, two of whom died. Non of these episodes occurred within two weeks of discharge from accident and emergency. Nine alternative admission policies to that employed in our study were compiled from various combinations of the clinical variables such as chest pain and the initial ECG. The number of inappropriate discharges from, and admissions to, accident and emergency are recorded for each admission policy. All nine failed to match the diagnostic accurary of the policy routinely employed by us in assessing these patients. The combination of careful history taking, physical examination, ECG changes, and the clinical judgment of the senior house officer give the best results in terms of diagnostic sensitivity and specificity among patients seen with chest pain in an accident and emergency department.
|Number of pages||4|
|Journal||Irish medical journal|
|Publication status||Published - 1988|