Candidates for Thrombolysis among Emergency Room Patients with Acute Chest Pain

doi:10.1059/0003-4819-110-12-957

Candidates for Thrombolysis among Emergency Room Patients with Acute Chest Pain

Potential True- and False-Positive Rates

Abstract

Study Objective: To assess the potential clinical impact of thrombolytic therapy for acute myocardial infarction by determining true-positive and false-positive rates of criteria for eligibility among emergency room patients with acute chest pain.

Design: Prospective multicenter cohort study.

Setting: Emergency rooms of three university and four community hospitals.

Patients: Emergency room patients (7734) with acute chest pain.

Measurements and Main Results: Only 261 (23%) of 1118 patients with acute myocardial infarctions were 75 years of age or younger, presented within 4 hours of the onset of pain, and had emergency room electrocardiograms showing probable acute myocardial infarction; 60 (0.9%) of the 6616 patients without infarction also met these criteria (positive predictive value, 261/321 = 81%; CI, 77% to 86%). The positive predictive value could increase to about 88% (CI, 82% to 93%) if eligibility were based on the official hospital electrocardiogram reading.

Conclusions: Because experience from published studies suggests that about one third of patients who meet these three eligibility criteria have other contraindications to thrombolysis, we estimate that about 15% of patients with acute myocardial infarction would meet the criteria for eligibility for thrombolysis that have been used in clinical trials at the time of emergency room presentation. Further, for every eight patients with true-positive results who are treated, one to two patients with false-positive results may also be treated if decisions are based on the interpretation of a single electrocardiogram.

Article and Author Information

From Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts; Yale-New Haven Hospital, and Yale University School of Medicine, New Haven, Connecticut; and University of Cincinnati Hospital, Cincinnati, Ohio. For current author addresses, see end of text.
The Chest Pain Study Group includes Lee Goldman, MD (co-principal investigator), Thomas H. Lee, MD, E. Francis Cook, ScD, Monica C. Weisberg, RN, Karen Daley, RN, and Barbara C. Rosen, BA, Brigham and Women's Hospital, Boston, Massachusetts; George Terranova, MD (site director), Carol Stasiulewicz, PA, and David Copen, MD, Danbury Hospital, Danbury, Connecticut; Alan Brandt, MD, (site director), and Jay Walshon, MD, Milford Hospital, Milford, Connecticut; Louis Gottlieb, MD (site director), St. Mary's Hospital, Waterbury, Connecticut; Gregory W. Rouan, MD (site director), Jerris R. Hedges, MD, Robert Toltzis, MD, and Beth Goldstein-Wayne, RN, University of Cincinnati Hospital, Cincinnati, Ohio; Michael Kobernick, MD (site director), Daniel Jones, MPH, and Carolyn Guidot, MD, William Beaumont Hospital, Royal Oak, Michigan; and Donald A. Brand, PhD (coprincipal investigator), Denise Acampora, MPH, John Mellors, MD, Kathryn Trainor, MS, Rita M. Jakubowski, RN, and Susan Healy, RN, Yale-New Haven Hospital, New Haven, Connecticut.
Grant Support: Supported in part by grants from the John A. Hartford Foundation, (83102-2H; Principal investigators: Dr. Brand and Dr. Goldman); and the Robert Wood Johnson Foundation (12543; Principal investigators, Dr. Goldman). Dr. Lee is the recipient of a Public Health Service Clinical Investigator Award (HLOl594-01) from the National Heart, Lung, and Blood Institute. Dr. Rouan is a Teaching and Research Scholar of the American College of Physicians and was supported in part by a grant to the Training Program in Clinical Effectiveness from the W.K. Kellogg Foundation.
Requests for Reprints: Lee Goldman, MD, Division of Clinical Epidemiology, Consolidated Department of Medicine, Brigham and Women's and Beth Israel Hospitals, 75 Francis Street, Boston, MA 02115.
Current Author Addresses: Drs. Lee, Goldman, and Ms. Weisberg: Division of Clinical Epidemiology, Consolidated Department of Medicine, Brigham and Women's and Beth Israel Hospitals, Boston, MA 02115.

Dr. Brand: Yale School of Organization and Management, New Haven, CT 06520.

Dr. Rouan: University of Cincinnati Medical Center, Department of Internal Medicine, Cincinnati, OH 45267-0535.