LETTER
Evaluation of Chest Pain in the Emergency Department
Richard V. Aghababian
15 August 1995 | Volume 123 Issue 4 | Pages 314-318
TO THE EDITOR:
As President of the American College of Emergency Physicians, I must comment on the editorial by Kaul and Abbott [1]. The authors are apparently unfamiliar with the capabilities of most emergency physicians. The authors state that "emergency department physicians, by the nature of their training are generalists, and not experts in cardiovascular medicine." I point out that emergency medicine has been recognized as a medical specialty by the American Board of Medical Specialties and that graduates of emergency residency programs have completed at least 36 months of training.
The authors correctly note that reports published in the emergency medicine and cardiology literature have shown that fewer than 50% of patients with acute myocardial infarction have diagnostic electrocardiography on initial presentation. I disagree with the statement that the skills of emergency physicians in interpreting electrocardiograms, particularly when the findings are subtle, cannot be expected to equal those of a cardiologist. Aufderheide and colleagues [2] found no statistically significant difference between emergency physicians' and cardiologists' interpretations of prehospital 12-lead electrocardiograms for the presence of acute myocardial infarction.
I agree that a single measurement of creatine kinase-MB levels may not be helpful in patients with acute chest pain in whom an electrocardiogram is nondiagnostic. The Emergency Medicine Cardiac Research Group reported that electrocardiograms, along with serial creatine kinase-MB determinations using immunochemical assays, can increase the diagnostic accuracy of myocardial infarction in the emergency department to more than 88% in 3 to 4 hours [3].
In hospitals in which cardiologists who can do angioplasty are not immediately available for consultation when requested by the emergency physician, they should be available in less than 30 minutes for patients who have atypical presentations, contraindications to thrombolytic therapy, unremitting pain, or evidence of cardiogenic shock.
Overall, the emphasis in the care of patients with myocardial infarction should be teamwork that leads to optimal care. The teamwork should result in the coordination of medical professionals with complementary diagnostic and therapeutic skills, leading finally to excellent patient care.
1. Kaul S, Abbott RD. Evaluation of chest pain in the emergency department (Editorial). Ann Intern Med. 1994; 121:976-8.
2. Aufderheide TP, Keelan MH. Milwaukee prehospital chest pain project, phase I: feasibility and accuracy of prehospital thrombolytic candidate selection. Am J Cardiol. 1992; 69:991-6.
3. Gibler WB, Young GP, Hedges JR, et al. The Emergency Medicine Cardiac Research Group: acute myocardial infarction in chest pain patients with nondiagnostic ECG. Serial CK-MB sampling in the emergency department. Ann Emerg Med. 1992; 21:504-12.
4. Graff LG, ed. Observation Medicine. Boston: Andover Medical; 1993.
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