• Hans Domanovits, Martin Schillinger, Monika Paulis, Fritz Rauscha, Jana Thoennissen, Mariam Nikfardjam, and Anton N Laggner.
• Department of Emergency Medicine, Medical School, Vienna General Hospital, University of Vienna, Waehringer Guertel 18-20/6, Austria. hans.domanovits@univie.ac.at
• Resuscitation. 2002 Oct 1; 55 (1): 9-16.

Study ObjectiveTo assess the safety and the accuracy of a 4 h stepwise diagnostic approach relying on clinical judgement in unselected patients with acute chest pain.DesignProspective cohort study.SettingEmergency department (ED) of a tertiary care university hospital.Patients1288 unselected patients presenting with acute chest pain.InterventionsAfter history and physical examination, clinical judgement (step I), governed the need for further patient evaluation: baseline 12 lead electrocardiogramm (ECG) and laboratory examinations (step II), serial 12 lead ECG and laboratory examinations after 4 h (step III), and 4 h troponin T measurement (step IV) to exclude or to confirm a coronary origin of chest pain. Patients were followed clinically for 6 months for future occurrence of cardiac events (myocardial infarction, percutaneous transluminal coronary angioplasty (PTCA), CABG, cardiac death), any death and for accuracy of the ED diagnosis in non-coronary chest pain patients.Measurements And ResultsChest pain was diagnosed to be coronary in origin in 381 and non-coronary in 907 patients, respectively. Cardiac events occurred during follow up in 240 (19%) of 1288 patients, in 233 of 381 (61%) with presumed coronary and seven of 907 (1%) with presumed non-coronary chest pain. Sensitivity, specificity, positive predictive value and negative predictive value for correct detection of coronary chest pain were 97, 86, 61 and 99%, respectively. In non-coronary chest pain patients the agreement between the ED diagnosis and the final diagnosis was good (kappa=0.71, 95% confidence interval (CI) 0.67-0.75).ConclusionsThe 4 h stepwise approach guided by clinical judgement was safe for ruling out impending cardiac events in unselected patients with acute chest pain. However, more extensive evaluation is necessary for accurate rule-in of coronary chest pain.

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