Differential diagnosis of chest discomfort and general approach to myocardial ischemia decision making

Evaluating the Patient With Chest Pain

Chest pain is one of the most common presenting symptoms in healthcare settings and one of the most difficult diagnostic challenges. A comprehensive history is the cornerstone of evaluation and diagnosis and one of the most important skills in distinguishing among the many causes of chest pain. Because the differential diagnosis for chest pain ranges from conditions as minor as muscle strain to life-threatening conditions, such as an acute myocardial infarction or dissecting thoracic aortic aneurysm, the advanced practice nurse must quickly and systematically assess the patient.

Emergency cardiac stress testing in the evaluation of emergency department patients with atypical chest pain

STUDY OBJECTIVES

To determine the feasibility, safety, and reliability of emergency cardiac treadmill exercise stress testing (CTEST) in the evaluation of emergency department patients with atypical chest pain.

DESIGN

Thirty-two patients with atypical chest pain, normal ECGs, and risk factor stratification having low-probability of coronary artery disease were evaluated prospectively using outpatient, emergency CTEST. Study patients were compared with a retrospectively selected sample of admitted patients diagnosed with atypical chest pain who met the study criteria and were evaluated with CTEST as inpatients. All patients had follow-up at three and six months after evaluation.

SETTING

University-affiliated community teaching hospital with 65,000 annual ED visits.

RESULTS

All patients had normal CTEST. No patient had evidence of coronary artery disease, myocardial infarction, or sudden death during the follow-up period. The average length of stay was 5.5 hours for emergency CTEST patients versus two days for inpatients. The average patient charge was $467 for ED evaluation with emergency CTEST versus $2,340 for inpatient evaluation.

CONCLUSION

Emergency CTEST is a safe, efficient, cost-effective, and practical method of evaluating selected ED patients with chest pain. It is a useful aid for clinical decision making and may help to prevent unnecessary hospital admissions.