The value of the ECG for decision-making at first medical contact in the patient with acute chest pain

Background/Objectives. Rapid risk stratification of the patient with acute chest pain is essential to select the best management. We investigated the value of the ECG at first medical contact to determine size of the ischaemic myocardial area and thereby severity of risk. Methods. In 386 patients with acute chest pain, ECG findings were correlated with the coronary angiogram. Using ST-segment deviation patterns the location of the coronary culprit lesion was predicted and thereby size of the area at risk. Four groups of patients were present. Those with a narrow QRS and a total 12-lead ST-segment deviation score of ≥5 mm (group 1) or ≤4 mm (group 2); a QRS width of ≥120 ms (group 3), and patients with previous coronary bypass grafting (CABG) or percutaneous coronary intervention (PCI) (group 4). Results. Correct coronary culprit lesion localisation was possible in 84% of the 185 patients in group 1, 40% of the total cohort. Accurate prediction was not possible in most patients in groups 2, 3 and 4, in spite of extensive coronary artery disease in group 3 and 4. Conclusions. Using the 12-lead ECG the size of the myocardial area at risk can be accurately predicted when the total ST-segment deviation score is ≥5 mm, allowing identification of those in need of a PCI. In most patients with bundle branch block, previous CABG or PCI, the ECG can not localise the culprit lesion. This approach simplifies and accelerates decision-making at first medical contact. (Neth Heart J 2010;18:301-6.)     

Addition of heart score to high-sensitivity troponin T versus conventional troponin T in risk stratification of patients with chest pain at the coronary emergency rooms

Patients with chest pain have a large impact on available resources in coronary emergency rooms (CER). Clinical judgement, ECG, risk scores and biomarkers guide in risk stratification. We investigated if high-sensitivity troponin T (HsT) and the HEART Score could contribute to risk stratification at the CER. All patients with chest pain, without elevated conventional troponin levels at presentation, were included. HsT levels were determined at admission (T1), at 4–6 h (T2) and 8–10 h after symptom onset (T3). The HEART Score was calculated as risk score for the occurrence of a major adverse cardiac event (MACE). Thirty days after discharge, occurrence of MACE was registered. Eighty-nine patients were included (overall mean age 61 years (range 20–90)). At presentation, 68 patients (76 %) had a HsT below cut-off value of 14 ng/l (mean HEART Score 3.7, range 1–9). Thirty-one of these 68 patients had a HEART Score between 1–3, no MACE occurred in this group. For 3 patients (4 %) HsT levels increased above 14 ng/l. These 3 patients had a HEART Score between 4–6. The majority of patients with chest pain can be safely discharged within 4–6 h after onset of symptoms using HsT and the HEART Score. In contrast, patients with initially normal HsT but a high HEART Score need longer follow-up and repeat HsT determination.