A Computer Protocol to Predict Myocardial Infarction in Emergency Department Patients with Chest Pain

To achieve more appropriate triage to the coronary care unit of patients presenting with acute chest pain, we used clinical data on 1379 patients at two hospitals to construct a simple computer protocol to predict the presence of myocardial infarction. When we tested this protocol prospectively in 4770 patients at two university hospitals and four community hospitals, the computer-derived protocol had a significantly higher specificity (74 vs. 71 percent) in predicting the absence of infarction than physicians deciding whether to admit patients to the coronary care unit, and it had a similar sensitivity in detecting the presence of infarction (88.0 vs. 87.8 percent). Decisions based solely on the computer protocol would have reduced the admission of patients without infarction to the coronary care unit by 11.5 percent without adversely affecting the admission of patients in whom emergent complications developed that required intensive care. Although this protocol should not be used to override careful clinical judgment in individual cases, the computer protocol for the most part yields accurate estimates of the probability of myocardial infarction. Decisions about admission to the coronary care unit based on the protocol would have been as effective as those actually made by the unaided physicians who cared for the patients, and less costly. Whether physicians who are aided by the protocol perform better than unaided physicians cannot be determined without further study. (N Engl J Med 1988; 318:797–803.) IN 1982, we reported on the performance at two hospitals of a preliminary version of a computer-derived protocol to aid in making a diagnosis in patients arriving at the emergency room with acute chest pain, and we suggested that this approach warranted further prospective testing. 1 Subsequently, other investigators 2 , 3 have reported on other decision aids for similar purposes. Pozen and colleagues demonstrated that physicians who were aided by a slight modification 2 of their earlier protocol 4 performed better than physicians who were not aided by the protocol, but they did not report on the accuracy of the protocol itself. Also, Tierney et . . .