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PubMed · 11103731

Provocative testing for chest pain.

F Lateef·W B Gibler
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Abstract

Since the first Chest Pain Center (CPC) was set up in 1981 to speed up the evaluation and treatment of patients with acute myocardial infarction, the original concept has been expanded to include rapid evaluation of chest pain patients with the appropriate streamlining of care and incorporation of the latest in technology. It has also been established that among patients presenting with acute chest pain, a very low-risk group with less than 5% probability of a coronary event can be identified. The recognition of this group could prevent unnecessary admissions, affording more appropriate patient care and improved cost-effectiveness. The efficient management of these chest pain patients requires that there be reductions in: (1) delays in therapy, (2) "soft" admissions, (3) inappropriate dispositions, and (4) cost. With time, provocative testing (PT) for chest pain patients has been brought forward to the frontline. PT methods are now being studied in hundreds of emergency department (ED) patients, followed up over several months to ascertain the predictive value of both positive and negative test results. More and more CPCs are now using PT as part of their management protocol, in terms of decision-making pertaining to prognostification, treatment and disposition. This could be in the form of the ECG graded exercise test (GXT), stress echocardiography (SE) and stress single-photon emission computed tomography (SPECT) radionuclide perfusion imaging. The GXT is fairly widely used currently, SE is gaining popularity and stress radionuclide perfusion imaging will perhaps gain more acceptance as the experience with its use as well as the number of randomized controlled studies increase. As we move into the new millennium, the emergency physicians must familiarize themselves with the latest in the state-of-the-art concepts and technology to render improved, up-to-date and more cost-effective patient care.

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Chest PainCost-Benefit AnalysisDecision MakingDiagnosis, DifferentialDobutamineEchocardiographyElectrocardiographyEmergency Service, HospitalExercise TestHeartHumansMyocardial InfarctionPatient Care PlanningPrognosisTomography, Emission-Computed, Single-PhotonJournal ArticleReview

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BibTeXRIS

F Lateef, W B Gibler. 2000. Provocative testing for chest pain.. https://doi.org/10.1053/ajem.2000.18023

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PubMed2007

Impact of a negative prior stress test on emergency physician disposition decision in ED patients with chest pain syndromes.

OBJECTIVE: Many emergency department (ED) patients with potential acute coronary syndromes (ACS) have prior visits and prior cardiac testing; however, the effect of knowledge of prior testing on the emergency physician disposition decision making is not known. We studied the impact of prior noninvasive testing (ie, stress testing) for myocardial ischemia on disposition decision making in ED patients with potential ACS. METHODS: We performed a prospective cohort study of ED patients with chest pain who received an electrocardiogram for potential ACS. Data included demographics, medical history, stress test history, and TIMI risk score. Patients were followed in-house; 30-day telephone interviews were performed for follow-up. Main outcomes were ED disposition (admit/discharge) and a composite of 30-day death, acute myocardial infarction, and revascularization stratified on the basis of prior stress testing known at the time of presentation. Standard statistical techniques were used with 95% confidence intervals (CI). RESULTS: There were 1853 patients enrolled and 97% had follow-up. Patients had a mean age of 53 +/- 14 years; 60% were women, 67% were black. There were 1491 (79%) patients without a prior stress test, 291 (16%) had a normal prior stress test result, and 89 (5%) had an abnormal prior stress test result. Admission rates were 92% (95% CI, 87%-98%) for patients with a prior abnormal stress test, 73% (95% CI, 67%-78%) for patients with a normal prior stress test, and 70% (95% CI, 67%-72%) for patients without a prior stress test. Adverse outcomes were the highest among patients with prior abnormal stress test but did not differ significantly between patients with no prior stress test and patients with prior normal stress test (10.1% [95% CI, 3.6-16.7%] vs 5.2% [95% CI, 4.1-6.4%] vs 4.8% [95% CI, 2.4-7.3%]). CONCLUSION: Patients without prior stress tests and patients with prior normal stress tests were admitted for potential ACS at the same rate and had the same 30-day cardiovascular event rates. This suggests that prior stress testing does not affect subsequent disposition decisions. Perhaps cardiac catheterization or computed tomography coronary angiograms would have more of an impact on subsequent visits, making them potentially more cost-effective in the low-risk patient.

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PubMed2007

Hypothesis: chest pain in primary spontaneous pneumothorax.

The mechanism of chest pain in spontaneous pneumothorax has never been discussed in the literature. It is proposed that this is due to acute parietal pleural irritation secondary to leakage of inflammatory material following bleb rupture, rather than the presence of interpleural air.

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