Diagnosing acute cardiac ischemia in the emergency department: a systematic review of the accuracy and clinical effect of current technologies.
OBJECTIVE
Acute cardiac ischemia (ACI) encompasses the diagnoses of unstable angina pectoris and acute myocardial infarction (AMI). Accurate diagnosis and triage of patients with ACI in the emergency department should increase survival for these patients and reduce unnecessary hospital admissions.


METHODS
We conducted a systematic review of the English-language literature published between 1966 and December 1998 on the accuracy and clinical effect of diagnostic technologies for ACI. We evaluated prospective and retrospective studies of adult patients who presented to the ED with symptoms suggesting ACI. Outcomes were diagnostic performance (test sensitivity and specificity) and measures of clinical effect. Meta-analyses were performed when appropriate. A decision and cost-effectiveness analysis was conducted that investigated various diagnostic strategies used in the diagnosis of ACI in the ED.


RESULTS
We screened 6,667 abstracts, reviewed 407 full articles, and included 106 articles articles in the main analysis. Single measurements of biomarkers at presentation to the ED have low sensitivity for AMI, although they have high specificity. Serial measurements greatly increase the sensitivity for AMI while maintaining their excellent specificity. Diagnostic technologies to evaluate ACI in selected populations, such as electrocardiography, sestamibi perfusion imaging, and stress ECG, may have very good to excellent sensitivity; however, they have not been sufficiently studied. The Goldman Chest Pain Protocol has good sensitivity (about 90%) for AMI but has not been shown to result in any differences in hospitalization rate, length of stay, or estimated costs in the single clinical effect study performed. Its applicability to patients with unstable angina pectoris has not been evaluated. The use of an Acute Cardiac Ischemia-Time-Insensitive Predictive Instrument led to the appropriate triage of 97% of patients with ACI presenting to the ED and reduced unnecessary hospitalizations.


CONCLUSIONS
Many of the current technologies remain underevaluated, especially regarding their clinical effect. The extent to which combinations of tests may provide better accuracy than any single test needs further study.
Lau
J
J
Evidence-based Practice Center, Division of Clinical Care Research, New England Medical Center, Boston, MA 02111, USA. jlau1@lifespan.org
Ioannidis
J P
JP
Balk
E M
EM
Milch
C
C
Terrin
N
N
Chew
P W
PW
Salem
D
D
D000208:Acute Disease; D000328:Adult; D000789:Angina, Unstable / Q000175:diagnosis*; D003362:Cost-Benefit Analysis; D003661:Decision Support Techniques; D004562:Electrocardiography / Q000191:economics / Q000592:standards; D004638:Emergency Treatment / Q000191:economics / Q000379:methods* / Q000592:standards*; D019317:Evidence-Based Medicine; D005080:Exercise Test / Q000191:economics / Q000592:standards; D017721:Hospital Costs / Q000706:statistics & numerical data; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D009203:Myocardial Infarction / Q000175:diagnosis*; D011446:Prospective Studies; D015203:Reproducibility of Results; D012189:Retrospective Studies; D012680:Sensitivity and Specificity; D013673:Technology Assessment, Biomedical; D016896:Treatment Outcome; D014218:Triage / Q000191:economics / Q000379:methods / Q000592:standards