title: Is the initial diagnostic impression of "noncardiac chest pain" adequate to exclude cardiac disease?
abstract: OBJECTIVE
  In patients presenting to the emergency department (ED) with an initial diagnostic impression of noncardiac chest pain, we determine the 30-day incidence of adverse cardiac events and characteristics associated with those events.
  
  
  METHODS
  The multicenter, prospectively collected Internet Tracking Registry for Acute Coronary Syndromes (i*tr ACS ) registry of patients with chest pain enrolled from June 1, 1999, to August 1, 2001, was reviewed. We included patients if the physician's initial diagnostic impression was noncardiac chest pain after the medical history, physical examination, and initial 12-lead ECG. ED records, inpatient records, and follow-up results were reviewed for evidence of an adverse cardiac event defined as ST-segment or non-ST-segment elevation myocardial infarction, unstable angina, revascularization, or cardiac death within 30 days.
  
  
  RESULTS
  Of 17,737 patients enrolled in i*tr ACS , 2,992 had an initial emergency physician impression of noncardiac chest pain. Of these, 85 (2.8%) patients had definite evidence for an adverse cardiac event. The adverse cardiac event group was older (61.2 versus 47.9 years), more likely to be men (58.6% versus 38.7%), and had a higher Acute Cardiac Ischemia-Time Insensitive Predictive Instrument score (26.1 versus 15.6). Factors associated with adverse cardiac events included hypercholesterolemia, diabetes, history of coronary artery disease, and history of congestive heart failure.
  
  
  CONCLUSIONS
  When the initial impression is noncardiac chest pain, high-risk features such as traditional cardiovascular risk factors or a history of coronary artery disease are associated with adverse cardiac events. In the absence of well-defined criteria, treating physicians should consider further evaluation before diagnosing patients with noncardiac chest pain if these features are present.
authors.affiliation: Department of Emergency Medicine, Wake Forest University, Winston-Salem, NC 27157-1089, USA. cmiller@wfubmc.edu
authors.forename: Chadwick D
authors.initials: CD
authors.lastname: Miller
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Lindsell
authors.forename: Sorabh
authors.initials: S
authors.lastname: Khandelwal
authors.forename: Abhinav
authors.initials: A
authors.lastname: Chandra
authors.forename: Charles V
authors.initials: CV
authors.lastname: Pollack
authors.forename: Brian R
authors.initials: BR
authors.lastname: Tiffany
authors.forename: Judd E
authors.initials: JE
authors.lastname: Hollander
authors.forename: W Brian
authors.initials: WB
authors.lastname: Gibler
authors.forename: James W
authors.initials: JW
authors.lastname: Hoekstra
mesh_terms: D000328:Adult; D000368:Aged; D000787:Angina Pectoris / Q000175:diagnosis*; D015415:Biomarkers / Q000097:blood; D002637:Chest Pain / Q000209:etiology*; D003937:Diagnosis, Differential; D003951:Diagnostic Errors; D004562:Electrocardiography; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000175:diagnosis; D017202:Myocardial Ischemia / Q000175:diagnosis*; D012042:Registries; D012307:Risk Factors
chemical_list: D015415:Biomarkers