BACKGROUND. Although previous investigations have suggested that 24 hours is required to exclude acute myocardial infarction in patients who are admitted to a coronary care unit for the evaluation of acute chest pain, we hypothesized that a 12-hour period might be adequate for patients with a low probability of infarction at the time of admission. METHODS. Using a Bayesian model, we developed a strategy to identify candidates for a shorter period of observation from an analysis of a derivation set of 976 patients with acute chest pain who were admitted to three teaching and four community hospitals. In the derivation set, patients whose clinical characteristics in the emergency room predicted a low (less than or equal to 7 percent) probability of myocardial infarction had only a 0.4 percent risk of infarction if they had neither abnormal levels of cardiac enzymes nor recurrent ischemic pain during the first 12 hours of hospitalization. In an independent testing set of 2684 patients from the seven hospitals, 957 admitted patients (36 percent) were classified as candidates for this 12-hour period of observation according to a previously published multivariate algorithm. Few of these patients were actually transferred from a monitored setting at 12 hours. RESULTS. Of the 771 candidates for a 12-hour period of observation who did not have enzyme abnormalities or recurrent pain during the first 12 hours, 4 (0.5 percent) were subsequently found to have acute myocardial infarction, and only 3 (0.4 percent) died after primary cardiac arrests, all of which occurred three to five days after admission. Rates of other major cardiovascular complications were low in the patients who might have been transferred from the coronary care unit after 12 hours with this strategy. In patients with a higher initial risk of infarction, the standard strategy of 24-hour observation identified all but 11 of 739 acute myocardial infarctions (1 percent). CONCLUSIONS. Emergency room clinical data can be used to identify a large subgroup of patients for whom a 12-hour period of observation is normally sufficient to exclude acute myocardial infarction. Patient-specific evaluation and treatment can then proceed without the restrictions imposed by "rule-out" protocols for myocardial infarction.
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Department of Medicine, Brigham and Women's Hospital, Boston, MA 02115.
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[Abstract][Full Text]
Sgarbossa, E. B., Pinski, S. L., Barbagelata, A., Underwood, D. A., Gates, K. B., Topol, E. J., Califf, R. M., Wagner, G. S., The GUSTO-1 (Global Utilization of Streptokinase a, , Tissue Plasminogen Activator for Occluded Coronary,
(1996). Electrocardiographic Diagnosis of Evolving Acute Myocardial Infarction in the Presence of Left Bundle-Branch Block. NEJM
334: 481-487
[Abstract][Full Text]
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]
Pauker, S. G., Kopelman, R. I.
(1994). Invasive Interventions. NEJM
331: 601-605
[Full Text]
Hamm, C. W.
(1994). New Serum Markers for Acute Myocardial Infarction. NEJM
331: 607-608
[Full Text]
Midgette, A. S., Wong, J. B., Beshansky, J. R., Porath, A., Fleming, C., Pauker, S. G.
(1994). Cost - Effectiueness of Streptokinase for Acute Myocardial Infarction: A Combined Meta-analysis and Decision Analysis of the Effects of Infarct Location and of Likelihood of Infarction. Med Decis Making
14: 108-117
[Abstract]
(1991). MI CAN BE RULED OUT WITHIN 12 HOURS IN SOME PATIENTS. JWatch General
1991: 1-1
[Full Text]
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