How good are we at predicting ischaemic chest pain?

Here’s a case I had recently:

62 year old male presents to the Emergency Department with what he calls a flare-up of his congestive cardiac failure. He states he is short of breath. He is a frequent presenter to the department with this complaint. He has not taken his frusemide for the past 48hours.

He states that he feels very tired.

His examination is as follows:

He is a well looking man with normal vitals

Heart sounds dual, no murmur. normal JVP, bilateral pitting oedema to mid calves.

Chest clear

Abdomen soft

His ECG and CXR are normal

Bloods including a troponin are normal.

I’m unsure of the diagnosis, but given he hasn’t taken his frusemide, I treat him with that.

I am going to discharge him, however it is late at night and he lives alone, so we decide to keep him in the department overnight.

In the morning, he looks well and feels better, but still lethargic, ECG is unchanged, but for some reason someone does a follow-up troponin and it is 4.

He is diagnosed with a NSTEMI and sent to cardiology.

So the question I posed was, “How good are we at diagnosing cardiac chest pain?” and “Are there some signs or symptoms such as shortness of breath that are more important than we may initially think they are?”

Pope et al(NEJM 2000;343:1167-1170) looked at the rate of missed diagnoses of cardiac ischaemia in the emergency department.

This was a study of some 10689 patients and the conclusion was that there was a subgroup of patients more likely not to be admitted, who had ischaemia or infarction.

Those more likely to not be admitted were: […]

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