G047: Hypertension associated to myocardial ischemia or psychiatric disorder at the E.R. in patients with chest pain and non-diagnostic ECG

Coronary artery disease (CAD), gastroenteric pathology, parietal chest pain and psychiatric disorder are usually found in various degree, in pts with chest pain (CP) and non-diagnostic ECG. In this study, we assessed pts with a validated clinical chest pain score (including hypertension) and a first line instrumental work up, for identification of pts at risk for coronary events. During 95–99, we evaluated a total of 5936 consecutive pts with CP and non-diagnostic ECG by a clinical score based on location, radiation, character of CP, associated risk factors and symptoms (Goldman NEJM 1996, Radensky JACC 1996). Psychiatric screening was obtained by The Hospital Anxiety and Depression Scale (HADS) questionnaire. Patients considered at low risk for cardiovascular events were discharged from the E.R. (n=3964; 67%); these pts had a 2% readmission rate, but only a 0.2% final diagnosis of CAD. In this subset of pts we found a pathologic score at HADS in 12% of pts and hypertension in only one/third of pts. Patients, considered at risk for cardiovascular events, were admitted to the Chest Pain Unit (CPU), for second line investigation (n=1972; 33%). Rest or Stress MIBI myocardial scintigraphy was performed in pts > 40 y or >3 risk factors. Exercise tolerance test (ETT) and stress-ECHO were performed in pts without risk factors for atherosclerosis or when the final diagnosis was still uncertain at 24 hours from admission. All pts with >1 positive test underwent urgent angiography. Evidence of CAD was found in 361 pts (6%) with no ECG abnormalities (angiographically confirmed in 93%) based on >1 test including ECG (46%), cardiac enzyme (39%), echocardiogram (15%), nuclear scan (11%) and exercise test (9%). Only 2% of these patients had HADS high score. In 1070 pts (18%) with non-diagnostic ECG abnormalities on admission, diagnosis was obtained within the firsts hours (of which 225 acute myocardial ischemia were transferred to CCU). In this subset HADS high score was present in 1% of pts and hypertension in two/third of pts. CPU-based management allowed a 76% early discharge (67% from E.R. and 9% from CPU) in pts with CP and non-diagnostic ECG avoiding inappropiate CCU admission. Patients with CAD showed lower score at HADS questionnaire and a higher rate of hypertension.