Indicators of low clinical risk

There is abundant evidence that low risk in patients presenting with chest pain can be

0733-8651/05/$ - see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.ccl.2005.08.016 recognized on presentation and that this group neither requires nor benefits from traditional intensive care or extended observation in a monitoring unit. Lee and colleagues [16] reported that in patients admitted to rule out a coronary event, those with < 5% probability of acute MI could be identified by type of chest pain, past history, and initial ECG. Extension of this approach to over 4600 such patients demonstrated that the initial clinical assessment could distinguish those with < 1% probability of major complications [17]. The prognostic utility of the initial ECG alone in patients admitted to rule out MI was demonstrated by Brush and colleagues [18] in their report that a negative ECG on admission was associated with a 0.6% rate of serious complications during hospitalization compared with a 14% incidence in those with an abnormal ECG [18]. An earlier study indicated that a normal ECG in patients admitted for preinfarction angina predicted benign early and late outcomes in contrast to ECG evidence of ischemia, which correlated with markedly increased cardiac morbidity and mortality [19]. These findings were confirmed by Schroeder and colleagues [20] in their report that in patients in whom MI was ruled out, ECG evidence of ischemia was associated with a 1-year mortality similar to that of post-MI patients. An important concept to emerge from these studies is that although the cause of chest pain is frequently elusive, basic clinical tools provide powerful estimates of cardiac risk.

Recognition of low clinical risk stimulated alternative approaches to conventional coronary care, such as reduced time in the CCU [21,22], direct admission to a step-down unit [23], and observation in a short stay unit [24]. Recent innovations in the management of low-risk patients include guidelines, critical pathways, new serum markers of cardiac injury, novel ECG monitoring systems, early noninvasive cardiac imaging, early treadmill exercise testing, coronary calcium screening in the ED, noninvasive coronary angiography by CT and conventional coronary angiography [8-15,21].

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