Charles A. Bertrand, M.D., FACP, DIM-CD (Ret.)
Associate Clinical Professor of Medicine at New York Medical College
and at the Medical University of South Carolina


What happens when you have chest pain and go to the emergency room - is it a heart attack? Or muscular? Or indigestion? Of course, these are some possibilities but there are many other possibilities as well. Therefore, accurate diagnosis is the key.

An excellent effort was made to answer such questions in a recent article by Pope and others titled "Missed Diagnosis of Acute Cardiac Ischemia in the Emergency Department," published in the New England Journal of Medicine, volume 342, No. 16, pp. 1163 to 1170 - 2000. Accurate answers were provided and the results clearly evaluated.

The word ischemia means deprivation of blood supply to an organ or tissue. Two types of heart attacks are so identified ? acute myocardial infarction (usually due to a blood clot) and the other type is called unstable angina (wherein chest pain is present and the circulation is impaired but no clot present).

Ten study hospitals were involved ? mainly in New England. 10,689 patients were studied and of these 17 percent did have acute cardiac ischemia. (889 had acute myocardial infarction and 966 had unstable angina. In total, 98 percent were diagnosed accurately. This report focused on the 2 percent not correctly diagnosed and therefore not hospitalized. This study was particularly good in that all patients who were discharged from the emergency room department were later re?evaluated in 24 to 72 hours and thus the study methods were excellent.

It was determined that missed diagnoses occurred slightly more often in non?white individuals, women under the age of 55 years and those with normal or near normal electrocardiograms. It is reassuring to know that an accurate diagnosis is made in 98 percent of the patients. The article highlights some ideas to improve accurate diagnosis. Being more aware of heart attacks in younger women and non-white individuals does help. But, one of the real problems is that the electrocardiogram may remain normal for a variable period of time and it may be necessary to observe the patient over a number of hours.

The advice provided on this website is intended to be general in nature and should not be relied upon for specific treatment. If you need personal medical attention please contact your physician.

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