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Normal ECG During Chest Pain Does Not Rule Out ACS

Among chest pain patients with normal initial ECGs, a similar percentage had acute coronary syndrome whether the ECG was performed when chest pain was present or absent.

A normal electrocardiogram does not exclude acute coronary syndrome (ACS) in patients who present with chest pain, but many clinicians believe that ACS is unlikely to be the cause of the chest pain if the normal ECG was obtained during a pain episode. To clarify this issue, these authors conducted a prospective, observational study of 387 patients who presented to an emergency department with chest pain, had normal initial ECGs, and were admitted for evaluation for ACS.

Patients were divided into two groups, based on whether they had active chest pain during acquisition of the normal initial ECG: 126 had chest pain and 261 did not. ACS was defined as non–ST-segment-elevation myocardial infarction, >70% stenosis on coronary angiography, or positive noninvasive cardiac stress test. The prevalence of ACS did not differ significantly between the groups that did and did not have chest pain when the normal initial ECG was obtained (16% and 20%).

Comment: Lack of changes on an ECG performed during chest pain often is thought to reduce the likelihood of ACS. Findings from this and a previous study (JW Emerg Med Dec 22 2006) show that this assumption is erroneous and that, in fact, the likelihood of serious cardiac disease in patients who present with chest pain and an initial normal ECG is the same whether or not chest pain was present when the ECG was obtained.

— Diane M. Birnbaumer, MD, FACEP

Published in Journal Watch Emergency Medicine June 12, 2009

Citation(s):

Turnipseed SD et al. Frequency of acute coronary syndrome in patients with normal electrocardiogram performed during presence or absence of chest pain. Acad Emerg Med 2009 Jun; 16:495.

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Reader Remarks:

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• EKG & ACS
  J Brown, 15 Jun 2009 4:26 PM EST
  How was "normal" defined?
• Normal ECG in ACS
  DR. Bob P., 15 Jun 2009 4:26 PM EST
  NIce to see these studies which confirm what many practicing physicians have noted without having studies to confirm their experinces.... [more]
• Patient with normal ECG is a common diagnostic trap,in the clinic and ER.
  Asad Kundi, National institute of cardiovascular diseases karachi, 15 Jun 2009 4:26 PM EST
  There are several studies on the diagnostic and prognostic importance of an intially normal (or unremarkable) ECG in a subject... [more]
• ques on ECG ED CP study
  Rocco Arcieri, Dallastown, PA, 15 Jun 2009 4:26 PM EST
  A provacative study if verified. I wonder why cardiac enzymes were not used as an endpoint? Why was 70 %... [more]
• ACS and nl EKG
  Bernard A. Yablin, URMC---retired, 15 Jun 2009 4:26 PM EST
  Yes,it happens!
• CHEST PAIN ACTION
  TEJINDER SINGH, canada, 15 Jun 2009 5:06 PM EST
  Does it imply that all chest pain patients be sent to ER for blood tests? (especially if one is dealing... [more]
• TIMI Risk Score for NSTEMI
  Molly E Martin, hospitalist program, 16 Jun 2009 6:06 PM EST
  This is interesting as the EKG goes into calculating the TIMI risk score at initial presentation. If it is normal... [more]
• How to proceed /
  Anjaneyulu Chitta, 16 Jun 2009 6:06 PM EST
  Even if Serial ECG s are normal over a period of 24 to 48 hrs does one have to subject... [more]
• Normal ECG with ACS
  Geraldine A Lee, Baker IDI Heart & Diabetes Research, 17 Jun 2009 3:03 PM EST
  Firstly, any ECG with an abnormal finding (even minor T wave changes) should be noted. Secondly, the patients' symptoms and... [more]
• treat the patient not the piece of paper (EKG strip)
  ERNA POLODEANU, American Embasyy Nouakchott, 11 Aug 2009 2:09 PM EST
  I entirely agree with Dr.Asad Kundi when he said "MANAGE THE PATIENT NOT THE EKG".Even in a nursing College in... [more]