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Clinical Decision-Making In Adult Chest Pain Patients With Electrocardiographic ST-Segment Elevation

January 2006

The electrocardiogram (ECG) is a valuable and oftenused tool for evaluating numerous patient complaints and scenarios in the ED. Perhaps the most frequent application of the ECG is the evaluation of the adult chest pain patient. In these patients, the ECG is used to establish the diagnosis of an acute coronary syndrome (ACS) or alternative cardiorespiratory ailment. (ACS is a term referring to patients with clinical evidence of acute myocardial ischemia: unstable angina (UA), ST-segment elevation myocardial infarction (STEMI), and non–ST-segment elevation myocardial infarction (NSTEMI). For more on ACS pathophysiology, clinical diagnosis, risk stratification, and therapeutics, click here to view Emergency Medicine PRACTICE, Volume 6, Number 4, Evidence-Based Risk Stratification Of Patients With Suspected UA/NSTEMI, April 2004. Furthermore, the ECG provides other clinically useful information in the ACS patient. The ECG is analyzed for signs of ST-segment elevation AMI (acute myocardial infarction), evidence of cardiac ischemia, determination of cardiac rhythm, and possible evidence of a noncardiac cause of the chief complaint (eg, pulmonary embolism, pericarditis). In patients with ACS, the ECG is used to assess the evolution of the syndrome, to determine the response to ED-delivered treatment, to assist in hospital disposition, and to predict the risk of cardiac complications, including mortality.

A primary goal of the emergency physician caring for the chest pain patient with an ECG that demonstrates ST-segment elevation (STE) is to differentiate STEMI from all other causes of ST-segment elevation. The American College of Cardiology/American Heart Association (ACC/AHA) currently recommends that fibrinolytic therapy be initiated (ideally) within 3 hours of presentation, and balloon angioplasty within 90 minutes of the onset of chest pain.1 There is substantial evidence that prompt opening of affected coronary arteries lowers rates of death, left ventricular dysfunction, and stroke.2

The widely recognized benefits of early diagnosis and rapid revascularization treatment of AMI have emphasized the importance of the ECG interpretation in the ED.3 In the case of the chest pain patient demonstrating STE resulting from a noninfarction syndrome, the correct diagnosis must be made — not only to offer appropriate management for that particular illness, but also to avoid the incorrect application of potentially dangerous therapies, such as fibrinolysis.4

The following discussion focuses on an algorithmic approach to the evaluation of the chest pain patient with electrocardiographic ST-segment elevation. While we urge the clinician to consider this approach in their medical decision-making in the setting of chest pain patients with electrocardiographic STE, strict adherence to this clinical pathway at the bedside is not recommended. Rather, our algorithm provides a systematic method for interpretation of the ECG with ST-segment elevation; its best use is illustrating the importance of a systematic approach to the interpretation of the ECG with ST-segment elevation. Throughout this article, please refer to the Clinical Pathway for the algorithm.

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