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Normal ECG During Chest Pain Does Not Rule Out ACS

• EKG & ACS
• Normal ECG in ACS
• Patient with normal ECG is a common diagnostic trap,in the clinic and ER.
• ques on ECG ED CP study
• ACS and nl EKG
• CHEST PAIN ACTION
• TIMI Risk Score for NSTEMI
• How to proceed /
• Normal ECG with ACS
• treat the patient not the piece of paper (EKG strip)

EKG & ACS

J Brown, 15 Jun 2009 4:26 PM EST

Competing interests: None declared

How was "normal" defined?

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Normal ECG in ACS

DR. Bob P., 15 Jun 2009 4:26 PM EST

Competing interests: None declared

NIce to see these studies which confirm what many practicing physicians have noted without having studies to confirm their experinces.

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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

Competing interests: None declared

There are several studies on the diagnostic and prognostic importance of an intially normal (or unremarkable) ECG in a subject with chest pain. Decisions regarding further management, based on initial normal ECG alone , may sometime prove to be a death trap for the patient.

For the General physicians and young cardiologist , in my opinion, the important aspect which need to be high lightened is that in patient with chest pain and initial normal ECG "Manage the patient not ECG "

For example initial normal ECG, during chest pain in a patient with following clinical features may have grave prognosis.

#1)Male with age greater than 60 years..

2)Pain described as pressure, radiating to arm, shoulder, neck, or jaw,with diaphoresis.

3) Past history of ACS

Such patient, even with initial normal ECG in ER may have significant underlying coronary artery disease.

Young physicians should be trained, not to base their judgment on single test, but develop the skill and art of integrating the screening tests (ECG in this case) with clinical senora.

#Rouan GW, Lee TH, Cook EF, Brand DA, Weisberg MC, Goldman L. Clinical characteristics and outcome of acute myocardial infarction in patients with initially normal or nonspecific electrocardiograms (a report from the Multicenter Chest Pain Study). Am J Cardiol 1989;64:1087-92.

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ques on ECG ED CP study

Rocco Arcieri, Dallastown, PA, 15 Jun 2009 4:26 PM EST

Competing interests: None declared

A provacative study if verified. I wonder why cardiac enzymes were not used as an endpoint? Why was 70 % stenosis used on angiography(as opposed to 80, 85, 95 percent lesions--were all the 70% percent lesions culprit and subjected to intervention)? If angiography is used as an endpoint why is a positive stress test also used (presumably, all positive stress tests would be followed by cath to rule out false positives)?

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ACS and nl EKG

Bernard A. Yablin, URMC---retired, 15 Jun 2009 4:26 PM EST

Competing interests: None declared

Yes,it happens!

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CHEST PAIN ACTION

TEJINDER SINGH, canada, 15 Jun 2009 5:06 PM EST

Competing interests: None declared

Does it imply that all chest pain patients be sent to ER for blood tests? (especially if one is dealing with high risk group eg south east asians)

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TIMI Risk Score for NSTEMI

Molly E Martin, hospitalist program, 16 Jun 2009 6:06 PM EST

Competing interests: None declared

This is interesting as the EKG goes into calculating the TIMI risk score at initial presentation. If it is normal the risk of death death, recurrent MI goes down, according to the TIMI risk score.

I agree with above. I think biomarkers and possibly hard clinical end points, such as recurrent MI and death from CAD should have been used as endpoints. Not positive stress tests and 70% stenosis on angiography.

I'm not sure this study will change my practice as management is based on a gestalt not a single finding.. I will continue to be reassured by a negative EKG if my initial pre-test probability is low. Anyone disagree?

A "young physician's" perspective.

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How to proceed /

Anjaneyulu Chitta, 16 Jun 2009 6:06 PM EST

Competing interests: Nil

Even if Serial ECG s are normal over a period of 24 to 48 hrs does one have to subject the patient for angiogram? Are all such Chest Pains are necessarily ACS?

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Normal ECG with ACS

Geraldine A Lee, Baker IDI Heart & Diabetes Research, 17 Jun 2009 3:03 PM EST

Competing interests: None declared

Firstly, any ECG with an abnormal finding (even minor T wave changes) should be noted. Secondly, the patients' symptoms and cardiovascular risk profile are probably going to inform practice also but often these are not documented and a reliance on ECG and Troponin is more prevalent. The pathology should be used to confirm assessment findings rather than confirming initial provisional diagnosis.

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treat the patient not the piece of paper (EKG strip)

ERNA POLODEANU, American Embasyy Nouakchott, 11 Aug 2009 2:09 PM EST

Competing interests: None declared

I entirely agree with Dr.Asad Kundi when he said "MANAGE THE PATIENT NOT THE EKG".Even in a nursing College in Romania the students were tought to "TREAT THE PATIENT NOT THE PIECE OF PAPER".

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