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Previous Volume 334:1498-1504 June 6, 1996 Number 23 Next

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ABSTRACT

Background Patients who come to the emergency department with chest pain are a heterogeneous group. Some have ischemic heart disease that may lead to serious complications, whereas others have minor disorders. We performed a study to identify clinical factors that predict which patients will have complications requiring intensive care.

Methods We first studied 10,682 patients with acute chest pain at seven hospitals between 1984 and 1986 (derivation set) to identify potential clinical predictors of the development of major complications. We then validated these predictors in a separate set of 4676 patients at one hospital between 1990 and 1994 (validation set).

Results In the derivation set of patients, we identified the following clinical features, which, if present in the emergency department, were associated with an increased risk of complications: ST-segment elevation or Q waves on the electrocardiogram thought to indicate acute myocardial infarction, other electrocardiographic changes indicating myocardial ischemia, low systolic blood pressure, pulmonary rales above the bases, or an exacerbation of known ischemic heart disease. On the basis of these criteria, the patients in the validation set were stratified into four groups, with the risk of major complications in the first 12 hours ranging from 0.15 to 8 percent. After 12 hours, the probability of a major complication could be updated on the basis of whether the patient had already had a complication of major severity, a complication of intermediate severity, or a myocardial infarction (independent relative risks, 18.9, 7.7, and 4.0, respectively, as compared with patients without prior complications or myocardial infarction).

Conclusions The risk of major complications in patients with acute chest pain can be estimated on the basis of the clinical presentation and new clinical observations made during the hospital course. These estimates of risk help in making rational decisions about the appropriate level of medical care for patients with acute chest pain.

Source Information

From the Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco (L.G.); the Division of Clinical Epidemiology (E.F.C., P.A.J., T.H.L.), Cardiovascular Division (P.A.J., T.H.L.), and Division of General Medicine (E.F.C., T.H.L.), Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston; the Department of Epidemiology, Harvard School of Public Health, Boston (E.F.C.); the Primary Care Research Unit and Department of Medicine, New York Medical College, Valhalla (D.A.B.), and the Division of General Internal Medicine, University of Cincinnati Medical Center, Cincinnati (G.W.R.).

Address reprint requests to Dr. Goldman at the Department of Medicine, University of California, San Francisco, School of Medicine, 505 Parnassus Ave., San Francisco, CA 94143.

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