Missed diagnoses of acute myocardial infarction in the emergency department: Results from a multicenter study

doi:10.1016/S0196-0644(05)81945-6

Annals of Emergency Medicine

Volume 22, Issue 3, March 1993, Pages 579-582

https://doi.org/10.1016/S0196-0644(05)81945-6 Get rights and content

Study objective:

To determine the rate of missed acute myocardial infarction (AMI) in the emergency department and the factors related to missed diagnoses.

Study design:

Observational and case-control study.

Setting:

Data were analyzed from a multicenter study of coronary care unit admitting practices that included patients who presented to the ED with chest pain or other symptoms suggestive of acute cardiac ischemia (N = 5,773). Patients with missed AMI (cases) were compared with control patients admitted with AMI and to a second control group of patients discharged without AMI.

Results:

Of 1,050 patients with AMI, 20 (1.9%; 95% confidence interval, 1.2–2.9%) were not admitted. Patients with missed AMI were significantly less likely to have ECG changes and a history of AMI or nitroglycerin use than patients admitted with AMI. However, they were significantly more likely to have ECG changes than patients discharged without AMI. Five patients with missed AMI (25%) had ST-segment elevation, and seven (35%) were discharged with a diagnosis of ischemic heart disease by the physician in the ED. Death or potentially lethal complications occurred in 25% of missed AMI patients.

Conclusion:

The rate of missed AMI in the ED was only 1.9%. However, 25% of these might have been prevented had ST-elevation not been missed, and another 25% might have been prevented had patients who were recognized to have ischemic heart disease by the physician in the ED been admitted.

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Characteristics and Outcomes of Patients Hospitalized With Suspected Acute Coronary Syndrome in Whom the Diagnosis is not Confirmed
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Patients admitted with suspected acute coronary syndrome (ACS) in whom the diagnosis is not confirmed are poorly characterized. In a contemporary registry of consecutive patients hospitalized with suspected ACS as the primary diagnosis, we assessed characteristics on admission and in-hospital and 6-month mortality of patients discharged with other diagnoses and compared this subgroup with true ACS patients. Of 2557 patients included, 9.0% were discharged with a non-ACS diagnosis such as nonspecific chest pain, myopericarditis, stress cardiomyopathy, hemodynamic disturbances, heart failure, myocardial, pulmonary or valvular disease, or others. Compared with true ACS patients, those with other diagnoses were younger, more often female, and had less cardiovascular risk factors. Both groups had comparable rates of nonchest pain presentation and similar hemodynamic characteristics on admission. Non-ACS patients presented less often with Q waves or with ST-segment or T-wave changes and had a lower Global Registry of Acute Coronary Events score than true ACS patients. In-hospital (4.3 vs 4.0%, respectively, p = 0.834) and 6-month (5.4 vs 8.0%, respectively, p = 0.163) mortality rates were comparable in both groups. However, if patients in the non-ACS group were divided into subgroups with nonspecific chest pain (6.2% of total) or other diagnoses (2.8% of total), major differences in in-hospital (0.0 vs 13.9%, respectively, p < 0.001) and 6-month (0.7 vs 15.7%, respectively, p < 0.001) mortality rates would become apparent and remain after multivariable adjustment. In conclusion, in a non-negligible proportion of patients hospitalized with suspected ACS, this diagnosis is not confirmed. Prognosis of these patients follows a bimodal pattern, being excellent in those with nonspecific chest pain but worse than that of true ACS patients in the rest. Efforts are necessary to ensure prompt identification and early risk stratification of these patients allowing appropriate management decisions.

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: This study was supported by grants RO1 HS02068 and RO1 HS5549 from the Agency for Health Care Policy and Research (formerly the National Center for Health Services Research).

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Brief reportMissed diagnoses of acute myocardial infarction in the emergency department: Results from a multicenter study

Study objective:

Study design:

Setting:

Results:

Conclusion:

Am Heart J

Am J Cardiol

Clinical characteristics and natural history of patients sent home from the emergency room

Am J Cardiol

Disposition of presumed coronary patients from an emergency room

JAMA

Brief report
Missed diagnoses of acute myocardial infarction in the emergency department: Results from a multicenter study