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      Factors Predisposing to a Nonadmission of Patients with Acute Myocardial Infarction

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          Abstract

          Among patients presenting at the hospital with an acute myocardial infarction (AMI), about 2–6% are mistakenly discharged by emergency physicians. The relevance of diagnostic problems in the prehospital period of an AMI is unknown. We prospectively studied 421 patients seen by a primary care physician in the prehospital period of an AMI. Using a standardized interview, data were obtained to identify factors determining nonadmission. Of 421 AMI patients, 327 (77.7%) were directly admitted to hospital after examination by the physician, whereas 94 (22.3%) were not admitted. The median prehospital delay was 240 min in admitted and 2,200 min in nonadmitted patients. Using a stepwise logistic regression model, the following factors were identified as independent contributors to nonadmission: the patient not being much affected by the symptoms (2.48; 1.40–4.39), improvement of symptoms (2.59; 1.46–4.59), the patient not thinking to suffer an AMI (2.33; 1.28–4.17) and the patient being unable to imagine having a heart disease (1.93; 1.07–3.46). Conclusion: Nonadmission of AMI patients by health care professionals is a common problem. Several aspects of AMI presentation including the often limited intensity of symptoms and the variability of the clinical course may have to be re-emphasized by cardiologists. Taking a very careful history and being circumspect about the patient’s interpretation of symptoms still are the keys to a correct diagnosis of AMI.

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          Prevalence, clinical characteristics, and mortality among patients with myocardial infarction presenting without chest pain.

          John Canto (2000)
          Although chest pain is widely considered a key symptom in the diagnosis of myocardial infarction (MI), not all patients with MI present with chest pain. The extent to which this phenomenon occurs is largely unknown. To determine the frequency with which patients with MI present without chest pain and to examine their subsequent management and outcome. Prospective observational study. A total of 434,877 patients with confirmed MI enrolled June 1994 to March 1998 in the National Registry of Myocardial Infarction 2, which includes 1674 hospitals in the United States. Prevalence of presentation without chest pain; clinical characteristics, treatment, and mortality among MI patients without chest pain vs those with chest pain. Of all patients diagnosed as having MI, 142,445 (33%) did not have chest pain on presentation to the hospital. This group of MI patients was, on average, 7 years older than those with chest pain (74.2 vs 66.9 years), with a higher proportion of women (49.0% vs 38.0%) and patients with diabetes mellitus (32.6% vs 25. 4%) or prior heart failure (26.4% vs 12.3%). Also, MI patients without chest pain had a longer delay before hospital presentation (mean, 7.9 vs 5.3 hours), were less likely to be diagnosed as having confirmed MI at the time of admission (22.2% vs 50.3%), and were less likely to receive thrombolysis or primary angioplasty (25.3% vs 74.0%), aspirin (60.4% vs 84.5%), beta-blockers (28.0% vs 48.0%), or heparin (53.4% vs 83.2%). Myocardial infarction patients without chest pain had a 23.3% in-hospital mortality rate compared with 9.3% among patients with chest pain (adjusted odds ratio for mortality, 2. 21 [95% confidence interval, 2.17-2.26]). Our results suggest that patients without chest pain on presentation represent a large segment of the MI population and are at increased risk for delays in seeking medical attention, less aggressive treatments, and in-hospital mortality. JAMA. 2000;283:3223-3229
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            Missed Diagnoses of Acute Coronary Syndromes in the Emergency Room — Continuing Challenges

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              Author and article information

              Journal
              CRD
              Cardiology
              10.1159/issn.0008-6312
              Cardiology
              S. Karger AG
              0008-6312
              1421-9751
              2002
              September 2002
              26 September 2002
              : 98
              : 1-2
              : 75-80
              Affiliations
              aDepartment of Internal Medicine, University Teaching Hospital Itzehoe, Itzehoe, bDepartment of Internal Medicine, University Teaching Hospital Stralsund, Stralsund, cDivision of Cardiology, University Hospital Eppendorf, Hamburg, and dDepartment of Internal Medicine, University Teaching Hospital Konstanz, Konstanz, Germany
              Article
              64668 Cardiology 2002;98:75–80
              10.1159/000064668
              12373051
              dca0c709-66be-464c-85b0-b2072c9089f2
              © 2002 S. Karger AG, Basel

              Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

              History
              : 11 November 2001
              : 24 March 2002
              Page count
              Figures: 2, Tables: 1, References: 22, Pages: 6
              Categories
              Coronary Care

              General medicine,Neurology,Cardiovascular Medicine,Internal medicine,Nephrology
              Diagnostic errors,Myocardial infarction,Decision making

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