Missed Diagnoses of Acute Cardiac Ischemia in the Emergency Department
J. Hector Pope, M.D., Tom P. Aufderheide, M.D., Robin Ruthazer, M.P.H., Robert H. Woolard, M.D., James A. Feldman, M.D., Joni R. Beshansky, R.N., M.P.H., John L. Griffith, Ph.D., and Harry P. Selker, M.D., M.S.P.H.
Background Discharging patients with acute myocardial infarctionor unstable angina from the emergency department because ofmissed diagnoses can have dire consequences. We studied theincidence of, factors related to, and clinical outcomes of failureto hospitalize patients with acute cardiac ischemia.
Methods We analyzed clinical data from a multicenter, prospectiveclinical trial of all patients with chest pain or other symptomssuggesting acute cardiac ischemia who presented to the emergencydepartments of 10 U.S. hospitals.
Results Of 10,689 patients, 17 percent ultimately met the criteriafor acute cardiac ischemia (8 percent had acute myocardial infarctionand 9 percent had unstable angina), 6 percent had stable angina,21 percent had other cardiac problems, and 55 percent had noncardiacproblems. Among the 889 patients with acute myocardial infarction,19 (2.1 percent) were mistakenly discharged from the emergencydepartment (95 percent confidence interval, 1.1 to 3.1 percent);among the 966 patients with unstable angina, 22 (2.3 percent)were mistakenly discharged (95 percent confidence interval,1.3 to 3.2 percent). Multivariable analysis showed that patientswho presented to the emergency department with acute cardiacischemia were more likely not to be hospitalized if they werewomen less than 55 years old (odds ratio for discharge, 6.7;95 percent confidence interval, 1.4 to 32.5), were nonwhite(odds ratio, 2.2; 1.1 to 4.3), reported shortness of breathas their chief symptom (odds ratio, 2.7; 1.1 to 6.5), or hada normal or nondiagnostic electrocardiogram (odds ratio, 3.3;1.7 to 6.3). Patients with acute infarction were more likelynot to be hospitalized if they were nonwhite (odds ratio fordischarge, 4.5; 95 percent confidence interval, 1.8 to 11.8)or had a normal or nondiagnostic electrocardiogram (odds ratio,7.7; 95 percent confidence interval, 2.9 to 20.2). For the patientswith acute infarction, the risk-adjusted mortality ratio forthose who were not hospitalized, as compared with those whowere, was 1.9 (95 percent confidence interval, 0.7 to 5.2),and for the patients with unstable angina, it was 1.7 (95 percentconfidence interval, 0.2 to 17.0).
Conclusions The percentage of patients who present to the emergencydepartment with acute myocardial infarction or unstable anginawho are not hospitalized is low, but the discharge of such patientsmay be associated with increased mortality. Failure to hospitalizeis related to race, sex, and the absence of typical featuresof cardiac ischemia. Efforts to reduce the number of misseddiagnoses are warranted.
Source Information
From the Center for Cardiovascular Health Services Research, Division of Clinical Care Research, Department of Medicine, New England Medical Center, Boston (J.H.P., R.R., J.R.B., J.L.G., H.P.S.); the Department of Emergency Medicine, Baystate Medical Center, Springfield, Mass. (J.H.P.); the Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee (T.P.A.); the Department of Emergency Medicine, Rhode Island Hospital, Providence (R.H.W.); and the Department of Emergency Medicine, Boston Medical Center, Boston (J.A.F.).
Address reprint requests to Dr. Selker at the Division of Clinical Care Research, New England Medical Center, #63, 750 Washington St., Boston, MA 02111, or at hselker{at}lifespan.org.
Missed Diagnoses of Acute Cardiac Ischemia
Davidson S. J., Murphy D. G., Barbaro G., Giancaspro G., Soldini M., Kohn M. A., Gruber T., Potts J. L., Jordan D., Selker H. P., Feldman J. A., Pope J. H., Aufderheide T. P.
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N Engl J Med 2000;
343:1492-1494, Nov 16, 2000.
Correspondence
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