Missed ED Diagnosis of Acute Coronary Syndrome
Abstract & Commentary
Source: Pope JH, et al. Missed diagnosis of acute cardiac ischemia in the emergency department. N Engl J Med 2000;342:1163-1170.
The acute cardiac ischemia time-insensitive predictive Instrument (ACI-TIPI) trial, which served as the database for this paper, included data from 10 major centers on more than 10,000 patients age greater than 30 who presented to the ED with angina or anginal-equivalent symptoms. The authors sought to determine the incidence of failure to admit patients with acute coronary syndromes (ACS), defined as either acute myocardial infarction (AMI) or unstable angina. Analyzing these cases, they set out to identify factors related to the failure to admit and to review the clinical outcomes of those patients who were mistakenly discharged. In this trial, patients who were not admitted returned within 24-72 hours. Data were available on 99% of these patients, providing a good information source. One thousand eight hundred sixty-six of 10,689 patients (17%) met the criteria for ACS; 894 had AMI (8%) and 972 had unstable angina (9%). Excluding those patients leaving against medical advice (11 in total), 19 of 889 (2.1%) had a missed AMI, and 22 of 966 (2.3%) had unstable angina. The chart for one of those patients was not available. Review of the medical records of these 40 patients revealed the following key points:
• ED attendings saw more than 82.5% (but not all) of these patients.
• Two of 19 AMI patients had ECGs that were misread by the ED physician.
• Fourteen (74%) of 19 patients with AMI had non-Q wave infarctions.
• 53% of AMI patients and 62% of unstable angina patients had normal or non-diagnostic ECGs.
Multivariate analyses for all ACS patients revealed the following independent predictors of inappropriate discharge:
• female gender with age less than 55;
• nonwhite race;
• chief complaint of dyspnea (rather than chest pain);
• normal ECG.
A slight, statistically nonsignificant trend toward a higher risk-adjusted death rate was found in those patients with ACS who were discharged.
Comment by Richard A. Harrigan, MD, FAAEM
How you interpret these findings may depend upon whether you typically see the glass as half-full or half-empty. The accompanying editorial emphasizes that the miss rate in this study is consistent with the findings in a number of earlier studies.1 Of course, if you are one of the 2.1% of patients discharged with an AMI (or one of the physicians discharging), the company you keep is of little consolation. One number that should have certainly improved since these data were gathered in 1993 is the number of patients not seen by an attending ED physician. This number should now be zero at all institutions that do not rely on resident moonlighting. The authors point out that well-established chest pain centers did not fare better in this trial. However, the current state of serum cardiac markers and cardiac imaging has advanced since that time, and one hopes this would have a positive influence on inappropriate discharge rates.2 v
References
1. Mehta RH, Eagle KA. Missed diagnosis of acute coronary syndromes in the emergency room—Continuing challenges. N Engl J Med 2000;342:1207-1209.
2. Lee TH, Goldman L. Evaluation of the patient with acute chest pain. N Engl J Med 2000;342:1187-1195.
Which of the following variables was found to independently predict inappropriate discharge from the ED with an acute coronary syndrome?
a. African-American race
b. Age > 55
c. Chief complaint of shortness of breath
d. Left bundle branch block on the ECG
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