More than 7 million patients present to US emergency departments (EDs) with acute chest pain each year.22 Resting ECG is the first diagnostic test performed to screen for ischemia or infarction. More than half of these chest pain patients have a normal or nondiagnostic ECG, but such patients may still have an acute coronary syndrome.22
Missed MIs. Chest pain is the most common symptom of MI in both men and women. However, in a recent study, chest pain was found to be absent in 43% of women who had an acute MI.18 Women often present with "atypical" MI symptoms (see Symptoms of Heart Disease in Women). MI patients with atypical symptoms, especially those without chest pain, are the most likely to be mistakenly discharged rather than admitted for appropriate treatment.23
Up to 5% of patients who present to the ED with an actual acute MI are mistakenly discharged, and they have a worse prognosis than those who are appropriately hospitalized.23,24 Women are at a relatively high risk for unrecognized MI.25,26 In the Framingham study, 34.7% of women had unrecognized MI, compared with 27.7% in men.26
Unnecessary Admissions. On the other hand, patients are often admitted for further testing or treatment that is actually unnecessary because their chest pain was not caused by acute coronary syndromes, such as MI. Approximately a third of patients who present to the ED with chest pain actually have an acute coronary syndrome, but less than half of those admitted to the hospital are actually found to have such a condition.24 In 2000, it was estimated that the cost of these negative inpatient cardiac evaluations in the US alone was $6 billion.24
Improved Protocols for Chest Pain Assessment. Unrecognized MIs and the errant discharge of patients who need treatment result not only in adverse patient outcomes but also in medicolegal problems. Therefore, efforts to improve the assessment of patients who present with chest pain are ongoing.
Chest pain protocols that employ multiple modalities, including nuclear cardiac imaging, have been shown to22,27-30:
- Improve patient management
- Improve resource utilization and cost-effectiveness
- Reduce inappropriate admissions
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Facts About CAD in Women
Gender Differences
Symptoms
Chest Pain and Myocardial Infarction
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