To achieve more appropriate triage to the coronary care unit of patients presenting with acute chest pain, we used clinical data on 1379 patients at two hospitals to construct a simple computer protocol to predict the presence of myocardial infarction. When we tested this protocol prospectively in 4770 patients at two university hospitals and four community hospitals, the computer-derived protocol had a significantly higher specificity (74 vs. 71 percent) in predicting the absence of infarction than physicians deciding whether to admit patients to the coronary care unit, and it had a similar sensitivity in detecting the presence of infarction (88.0 vs. 87.8 percent). Decisions based solely on the computer protocol would have reduced the admission of patients without infarction to the coronary care unit by 11.5 percent without adversely affecting the admission of patients in whom emergent complications developed that required intensive care. Although this protocol should not be used to override careful clinical judgment in individual cases, the computer protocol for the most part yields accurate estimates of the probability of myocardial infarction. Decisions about admission to the coronary care unit based on the protocol would have been as effective as those actually made by the unaided physicians who cared for the patients, and less costly. Whether physicians who are aided by the protocol perform better than unaided physicians cannot be determined without further study.
Source Information
Joint Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115.
This article has been cited by other articles:
Miller, C D, Fermann, G J, Lindsell, C J, Mahaffey, K W, Peacock, W F, Pollack, C V, Hollander, J E, Diercks, D B, Gibler, W B, J W Hoekstra on behalf of the EMCREG-International,
(2008). Initial risk stratification and presenting characteristics of patients with evolving myocardial infarctions. Emerg. Med. J.
25: 492-497
[Abstract][Full Text]
Ladapo, J. A., Hoffmann, U., Bamberg, F., Nagurney, J. T., Cutler, D. M., Weinstein, M. C., Gazelle, G. S.
(2008). Cost-Effectiveness of Coronary MDCT in the Triage of Patients with Acute Chest Pain. Am. J. Roentgenol.
191: 455-463
[Abstract][Full Text]
Hagberg, S. M., Woitalla, F., Crawford, P.
(2008). 2002 ACC/AHA Guideline Versus Clinician Judgment as Diagnostic Tests for Chest Pain. J Am Board Fam Med
21: 101-107
[Abstract][Full Text]
Sequist, T. D., Marshall, R., Lampert, S., Buechler, E. J., Lee, T. H.
(2006). Missed opportunities in the primary care management of early acute ischemic heart disease.. Arch Intern Med
166: 2237-2243
[Abstract][Full Text]
Takahashi, O., Cook, E.F., Nakamura, T., Saito, J., Ikawa, F., Fukui, T.
(2006). Risk stratification for in-hospital mortality in spontaneous intracerebral haemorrhage: A Classification and Regression Tree Analysis. QJM
99: 743-750
[Abstract][Full Text]
Chaudhry, B., Wang, J., Wu, S., Maglione, M., Mojica, W., Roth, E., Morton, S. C., Shekelle, P. G.
(2006). Systematic Review: Impact of Health Information Technology on Quality, Efficiency, and Costs of Medical Care. ANN INTERN MED
144: 742-752
[Abstract][Full Text]
Reilly, B. M., Evans, A. T.
(2006). Translating Clinical Research into Clinical Practice: Impact of Using Prediction Rules To Make Decisions. ANN INTERN MED
144: 201-209
[Abstract][Full Text]
Lai, F., Macmillan, J., Daudelin, D. H., Kent, D. M.
(2006). The Potential of Training to Increase Acceptance and Use of Computerized Decision Support Systems for Medical Diagnosis. Human Factors: The Journal of the Human Factors and Ergonomics Society
48: 95-108
[Abstract]
Swap, C. J., Nagurney, J. T.
(2005). Value and Limitations of Chest Pain History in the Evaluation of Patients With Suspected Acute Coronary Syndromes. JAMA
294: 2623-2629
[Abstract][Full Text]
Mitchell, A. M., Brown, M. D., Menown, I. B.A., Kline, J. A.
(2005). Novel Protein Markers of Acute Coronary Syndrome Complications in Low-Risk Outpatients: A Systematic Review of Potential Use in the Emergency Department. Clin. Chem.
51: 2005-2012
[Abstract][Full Text]
Guzelian, P. S, Victoroff, M. S, Halmes, N C., James, R. C, Guzelian, C. P
(2005). Evidence-based toxicology: a comprehensive framework for causation. Hum Exp Toxicol
24: 161-201
[Abstract]
Abadie, J. M., Blassingame, C. L., Bankson, D. D.
(2005). Albumin Cobalt Binding Assay to Rule Out Acute Coronary Syndrome. Annals of Clinical & Laboratory Science
35: 66-72
[Abstract][Full Text]
Christenson, J., Innes, G., McKnight, D., Boychuk, B., Grafstein, E., Thompson, C. R., Rosenberg, F., Anis, A. H., Gin, K., Tilley, J., Wong, H., Singer, J.
(2004). Safety and efficiency of emergency department assessment of chest discomfort. CMAJ
170: 1803-1807
[Abstract][Full Text]
Goodacre, S., Nicholl, J., Dixon, S., Cross, E., Angelini, K., Arnold, J., Revill, S., Locker, T., Capewell, S. J, Quinney, D., Campbell, S., Morris, F.
(2004). Randomised controlled trial and economic evaluation of a chest pain observation unit compared with routine care. BMJ
328: 254-
[Abstract][Full Text]
Goldman, L., Kirtane, A. J.
(2003). Triage of Patients with Acute Chest Pain and Possible Cardiac Ischemia: The Elusive Search for Diagnostic Perfection. ANN INTERN MED
139: 987-995
[Abstract][Full Text]
Goodacre, S, Calvert, N
(2003). Cost effectiveness of diagnostic strategies for patients with acute, undifferentiated chest pain. Emerg. Med. J.
20: 429-433
[Abstract][Full Text]
Medow, M. A., Weed, H. G., Schuller, D. E.
(2002). Simple Predictors of Survival in Head and Neck Squamous Cell Carcinoma. Arch Otolaryngol Head Neck Surg
128: 1282-1286
[Abstract][Full Text]
Erhardt, L., Herlitz, J., Bossaert, L., Halinen, M., Keltai, M., Koster, R., Marcassa, C., Quinn, T., van Weert, H.
(2002). Task force on the management of chest pain. Eur Heart J
23: 1153-1176
[Full Text]
Snider, A., Papaleo, M., Beldner, S., Park, C., Katechis, D., Galinkin, D., Fein, A.
(2002). Is Telemetry Monitoring Necessary in Low-Risk Suspected Acute Chest Pain Syndromes?*. Chest
122: 517-523
[Abstract][Full Text]
Reilly, B. M., Evans, A. T., Schaider, J. J., Das, K., Calvin, J. E., Moran, L. A., Roberts, R. R., Martinez, E.
(2002). Impact of a Clinical Decision Rule on Hospital Triage of Patients With Suspected Acute Cardiac Ischemia in the Emergency Department. JAMA
288: 342-350
[Abstract][Full Text]
Goodacre, S W, Morris, F M, Campbell, S, Arnold, J, Angelini, K
(2002). A prospective, observational study of a chest pain observation unit in a British hospital. Emerg. Med. J.
19: 117-121
[Abstract][Full Text]
Hripcsak, G., Wilcox, A.
(2002). Reference Standards, Judges, and Comparison Subjects: Roles for Experts in Evaluating System Performance. J. Am. Med. Inform. Assoc.
9: 1-15
[Abstract][Full Text]
Kohn, M. A., Newman, T. B.
(2001). What White Blood Cell Count Should Prompt Antibiotic Treatment in a Febrile Child? Tutorial on the Importance of Disease Likelihood to the Interpretation of Diagnostic Tests. Med Decis Making
21: 479-489
[Abstract]
Fletcher, G. F., Balady, G. J., Amsterdam, E. A., Chaitman, B., Eckel, R., Fleg, J., Froelicher, V. F., Leon, A. S., Pina, I. L., Rodney, R., Simons-Morton, D. A., Williams, M. A., Bazzarre, T.
(2001). Exercise Standards for Testing and Training: A Statement for Healthcare Professionals From the American Heart Association. Circulation
104: 1694-1740
[Full Text]
deFilippi, C. R., Rosanio, S., Tocchi, M., Parmar, R. J., Potter, M. A., Uretsky, B. F., Runge, M. S.
(2001). Randomized comparison of a strategy of predischarge coronary angiography versus exercise testing in low-risk patients in a chest pain unit: in-hospital and long-term outcomes. J Am Coll Cardiol
37: 2042-2049
[Abstract][Full Text]
Lewis, W. R., Amsterdam, E. A.
(2001). Defining the role of chest pain units. J Am Coll Cardiol
37: 2050-2052
[Full Text]
Paventi, S., Parafati, M. A., Di Luzio, E., Pellegrino, C. A.
(2001). Safety and Feasibility of Two-Dimensional Echocardiography and Myocardial Perfusion Imaging in Patients with Chest Pain. ANGIOLOGY
52: 305-309
[Abstract]
Graff, L.
(2001). Three generations of recurrent dislocated shoulders.. Emerg. Med. J.
18: 148-149
[Full Text]
Bholasingh, R, de Winter, R J, Fischer, J C, Koster, R W, Peters, R J G, Sanders, G T
(2001). Safe discharge from the cardiac emergency room with a rapid rule-out myocardial infarction protocol using serial CK-MBmass. Heart
85: 143-148
[Abstract][Full Text]
Herren, K R, Mackway-Jones, K
(2001). Emergency management of cardiac chest pain: a review. Emerg. Med. J.
18: 6-10
[Full Text]
Goodacre, S., Morris, F., Arnold, J., Angelini, K.
(2001). Is a chest pain observation unit likely to be cost saving in a British hospital?. Emerg. Med. J.
18: 11-14
[Abstract][Full Text]
Calvin, J. E., Klein, L. W., VandenBerg, E. J., Meyer, P., Parrillo, J. E.
(2000). Validated risk stratification model accurately predicts low risk in patients with unstable angina. J Am Coll Cardiol
36: 1803-1808
[Abstract][Full Text]
Stein, R. A., Chaitman, B. R., Balady, G. J., Fleg, J. L., Limacher, M. C., Pina, I. L., Williams, M. A., Bazzarre, T.
(2000). Safety and Utility of Exercise Testing in Emergency Room Chest Pain Centers : An Advisory From the Committee on Exercise, Rehabilitation, and Prevention, Council on Clinical Cardiology, American Heart Association. Circulation
102: 1463-1467
[Full Text]
Braunwald, E., Antman, E. M., Beasley, J. W., Califf, R. M., Cheitlin, M. D., Hochman, J. S., Jones, R. H., Kereiakes, D., Kupersmith, J., Levin, T. N., Pepine, C. J., Schaeffer, J. W., Smith, E. E. III, Steward, D. E., Theroux, P., Gibbons, R. J., Alpert, J. S., Eagle, K. A., Faxon, D. P., Fuster, V., Gardner, T. J., Gregoratos, G., Russell, R. O., Smith, S. C. Jr
(2000). ACC/AHA guidelines for the management of patients with unstable angina and non-st-segment elevation myocardial infarction: A report of the american college of cardiology/ american heart association task force on practice guidelines (committee on the management of patients with unstable angina). J Am Coll Cardiol
36: 970-1062
[Full Text]
Quin, G.
(2000). Chest pain evaluation units. Emerg. Med. J.
17: 237-240
[Full Text]
Collinson, P O, Premachandram, S, Hashemi, K, Kennedy, R L.
(2000). Prospective audit of incidence of prognostically important myocardial damage in patients discharged from emergency department Commentary: Time for improved diagnosis and management of patients presenting with acute chest pain. BMJ
320: 1702-1705
[Abstract][Full Text]
deFilippi, C. R., Tocchi, M., Parmar, R. J., Rosanio, S., Abreo, G., Potter, M. A., Runge, M. S., Uretsky, B. F.
(2000). Cardiac troponin T in chest pain unit patients without ischemic electrocardiographic changes: angiographic correlates and long-term clinical outcomes. J Am Coll Cardiol
35: 1827-1834
[Abstract][Full Text]
(2000). Chest pain with nondiagnostic electrocardiogram in the emergency department: a randomized controlled trial of two cardiac marker regimens. CMAJ
162: 1561-1566
Lee, T. H., Goldman, L.
(2000). Evaluation of the Patient with Acute Chest Pain. NEJM
342: 1187-1195
[Full Text]
Mehta, R. H., Eagle, K. A.
(2000). Missed Diagnoses of Acute Coronary Syndromes in the Emergency Room -- Continuing Challenges. NEJM
342: 1207-1210
[Full Text]
Ewy, G. A., Ornato, J. P.
(2000). Emergency cardiac care: introduction. J Am Coll Cardiol
35: 825-880
[Full Text]
Polanczyk, C. A., Kuntz, K. M., Sacks, D. B., Johnson, P. A., Lee, T. H.
(1999). Emergency Department Triage Strategies for Acute Chest Pain Using Creatine Kinase-MB and Troponin I Assays: A Cost-Effectiveness Analysis. ANN INTERN MED
131: 909-918
[Abstract][Full Text]
Hillis, G S, Zhao, N, Taggart, P, Dalsey, W C, Mangione, A
(1999). Utility of cardiac troponin I, creatine kinase-MBmass, myosin light chain 1, and myoglobin in the early in-hospital triage of "high risk" patients with chest pain. Heart
82: 614-620
[Abstract][Full Text]
Hollander, J. E., Muttreja, M. R., Dalesandro, M. R., Shofer, F. S.
(1999). Risk stratification of emergency department patients with acute coronary syndromes using P-Selectin. J Am Coll Cardiol
34: 95-105
[Abstract][Full Text]
Lewis, W. R., Amsterdam, E. A., Turnipseed, S., Kirk, J. D.
(1999). Immediate exercise testing of low risk patients with known coronary artery disease presenting to the emergency department with chest pain. J Am Coll Cardiol
33: 1843-1847
[Abstract][Full Text]
Kontos, M. C., Jesse, R. L., Anderson, F. P., Schmidt, K. L., Ornato, J. P., Tatum, J. L.
(1999). Comparison of Myocardial Perfusion Imaging and Cardiac Troponin I in Patients Admitted to the Emergency Department With Chest Pain. Circulation
99: 2073-2078
[Abstract][Full Text]
Newby, L. K., Mark, D. B.
(1998). The Chest-Pain Unit -- Ready for Prime Time?. NEJM
339: 1930-1932
[Full Text]
Panju, A. A., Hemmelgarn, B. R., Guyatt, G. H., Simel, D. L.
(1998). Is This Patient Having a Myocardial Infarction?. JAMA
280: 1256-1263
[Abstract][Full Text]
Rosenthal, G. E., Sirio, C. A., Shepardson, L. B., Harper, D. L., Rotondi, A. J., Cooper, G. S.
(1998). Use of Intensive Care Units for Patients With Low Severity of Illness. Arch Intern Med
158: 1144-1151
[Abstract][Full Text]
Roberts, R. R., Zalenski, R. J., Mensah, E. K., Rydman, R. J., Ciavarella, G., Gussow, L., Das, K., Kampe, L. M., Dickover, B., McDermott, M. F., Hart, A., Straus, H. E., Murphy, D. G., Rao, R.
(1997). Costs of an Emergency Department--Based Accelerated Diagnostic Protocol vs Hospitalization in Patients With Chest Pain: A Randomized Controlled Trial. JAMA
278: 1670-1676
[Abstract]
Zalenski, R. J., McCarren, M., Roberts, R., Rydman, R. J., Jovanovic, B., Das, K., Mendez, J., El-Khadra, M., Fraker, L., McDermott, M.
(1997). An Evaluation of a Chest Pain Diagnostic Protocol to Exclude Acute Cardiac Ischemia in the Emergency Department. Arch Intern Med
157: 1085-1091
[Abstract]
Katz, D. A., Griffith, J. L., Beshansky, J. R., Selker, H. P.
(1996). The Use of Empiric Clinical Data in the Evaluation of Practice Guidelines for Unstable Angina. JAMA
276: 1568-1574
[Abstract]
Chin, M. H., Goldman, L.
(1996). Correlates of Major Complications or Death in Patients Admitted to the Hospital With Congestive Heart Failure. Arch Intern Med
156: 1814-1820
[Abstract]
Tosteson, A. N.A., Goldman, L., Udvarhelyi, I. S., Lee, T. H.
(1996). Cost-effectiveness of a Coronary Care Unit Versus an Intermediate Care Unit for Emergency Department Patients With Chest Pain. Circulation
94: 143-150
[Abstract][Full Text]
Ackermann, R. J., Vogel, R. L., Levenson, J., Byrne, J., Liron, M., Sgarbossa, E. B., Pinski, S. L., Wagner, G. S.
(1996). Electrocardiographic Diagnosis of Acute Myocardial Infarction in the Presence of Left Bundle-Branch Block. NEJM
335: 131-133
[Full Text]
Goldman, L., Cook, E. F., Johnson, P. A., Brand, D. A., Rouan, G. W., Lee, T. H.
(1996). Prediction of the Need for Intensive Care in Patients Who Come to Emergency Departments with Acute Chest Pain. NEJM
334: 1498-1504
[Abstract][Full Text]
Lewis, W. R., Amsterdam, E. A.
(1996). Evaluation of the Patient With 'Rule Out Myocardial Infarction'. Arch Intern Med
156: 41-45
[Abstract]
Wyatt, J. C, Altman, D. G
(1995). Commentary: Prognostic models: clinically useful or quickly forgotten?. BMJ
311: 1539-1541
[Full Text]
Kellett, J., Clarke, J.
(1995). Comparison of "Accelerated" Tissue Plasminogen Activator with Streptokinase for Treatment of Suspected Myocardial Infarction. Med Decis Making
15: 297-310
[Abstract]
Brand, D. A., Quam, L., Leatherman, S.
(1995). Medical Practice Profiling: Concepts and Caveats. Med Care Res Rev
52: 223-251
[Abstract]
Hollander, J. E., Hoffman, R. S., Burstein, J. L., Shih, R. D., Thode, H. C. Jr, Cocaine-Associated Myocardial Infarction Study Gro, , Bartfield, J., Raccio-Robak, N., Harchelroad, F., Hoffman, R. S., Shih, R. D., Nelson, L., Sandoval, M., Feldman, J., Fish, S., Carter, W., Paynter, R., Whelan, C., Silverman, R., Scheppke, K., Thomaser, H., Doyon, S., Wax, P., Lopez, B. L., Nelson, L., Shih, R. D., Imbesi, J., Giroski, L., Hollander, J. E., Burstein, J., Shepherd, S. M., Sparkes, M., Seger, D., Goetz, R. J., Morgan, D. L., Wilhelm, G., Schumb, D., Sporer, K. A., Sutton, B., Ling, L. J., Wilson, L., Hoekstra, J., Kulig, K., Phillips, S., Brent, J., Kulig, K., Phillips, S., Brent, J., Watson, W. A., Quick, A. M., Hollander, J. E., Hoffman, R. S., Thodejr, H. C., Hollander, J. E., Hoffman, R. S., Burstein, J., Shih, R. D., Thode, H. C. Jr
(1995). Cocaine-Associated Myocardial Infarction: Mortality and Complications. Arch Intern Med
155: 1081-1086
[Abstract]
Puleo, P. R., Meyer, D., Wathen, C., Tawa, C. B., Wheeler, S., Hamburg, R. J., Ali, N., Obermueller, S. D., Triana, F. J., Zimmerman, J. L., Perryman, M. B., Roberts, R.
(1994). Use of a Rapid Assay of Subforms of Creatine Kinase MB to Diagnose or Rule Out Acute Myocardial Infarction. NEJM
331: 561-566
[Abstract][Full Text]
Baxt, W. G.
(1994). A Neural Network Trained to Identify the Presence of Myocardial Infarction Bases Some Decisions on Clinical Associations That Differ from Accepted Clinical Teaching. Med Decis Making
14: 217-222
[Abstract]
Baron, J. A.
(1994). Uncertainty in Bayes. Med Decis Making
14: 46-51
[Abstract]
Peirce, J. C., Cornell, R. G.
(1993). Integrating Stratum-specific Likelihood Ratios with the Analysis of ROC Curves. Med Decis Making
13: 141-151
[Abstract]
Shell, I. G., Greenberg, G. H., McKnight, R. D., Nair, R. C., McDowell, I., Reardon, M., Stewart, J. P., Maloney, J.
(1993). Decision Rules for the Use of Radiography in Acute Ankle Injuries: Refinement and Prospective Validation. JAMA
269: 1127-1132
[Abstract]
Miller, M. E., Langefeld, C. D., Tierney, W. M., Hui, S. L., McDonald, C. J.
(1993). Validation of Probabilistic Predictions. Med Decis Making
13: 49-57
[Abstract]
Keeler, E. B., Rubenstein, L. V., Kahn, K. L., Draper, D., Harrison, E. R., McGinty, M. J., Rogers, W. H., Brook, R. H.
(1992). Hospital Characteristics and Quality of Care. JAMA
268: 1709-1714
[Abstract]
Baxt, W. G.
(1991). Use of an Artificial Neural Network for the Diagnosis of Myocardial Infarction. ANN INTERN MED
115: 843-848
[Abstract]
Rolph, J. E., Kravitz, R. L., McGuigan, K.
(1991). Malpractice Claims Data as a Quality Improvement Tool: II. Is Targeting Effective?. JAMA
266: 2093-2097
[Abstract]
Weingarten, S., Ermann, B., Bolus, R., Riedinger, M. S., Rubin, H., Green, A., Karns, K., Ellrodt, A. G.
(1990). Early "Step-Down" Transfer of Low-Risk Patients with Chest Pain: A Controlled Interventional Trial. ANN INTERN MED
113: 283-289
[Abstract]
Dawson, N. V., Cebul, R. D.
(1990). Advances in Quantitative Techniques for Making Medical Decisions: The Last Decade. Eval Health Prof
13: 37-62
[Abstract]
Lee, T. H., Weisberg, M. C., Brand, D. A., Rouan, G. W., Goldman, L.
(1989). Candidates for Thrombolysis among Emergency Room Patients with Acute Chest Pain: Potential True- and False-Positive Rates. ANN INTERN MED
110: 957-962
[Abstract]
Pelberg, A. L.
(1989). Missed Myocardial Infarction in the Emergency Room. American Journal of Medical Quality
4: 39-42
[Abstract]
sager, P. T., Bhandari, A. K.
(1989). Atrial Fibrillation: Another Perspective. J Intensive Care Med
4: 95-96
Kalb, P. E., Miller, D. H.
(1989). Utilization Strategies for Intensive Care Units. JAMA
261: 2389-2395
[Abstract]
Dawson, N. V.
(1989). Comments on a Commentary. Med Decis Making
9: 68-69
Silverstein, M. D.
(1988). Prediction Instruments and Clinical Judgment in Critical Care. JAMA
260: 1758-1759
[Abstract]
LEE, T. H., GOLDMAN, L.
(1988). The Coronary Care Unit Turns 25: Historical Trends and Future Directions. ANN INTERN MED
108: 887-894
[Abstract]
(1988). A COMPUTERIZED PROTOCOL ACCURATELY DIAGNOSES MI. JWatch General
1988: 4-4
[Full Text]
