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New ways to assess cardiac risk would be helpful

Chest pain prompts six million patient visits to U.S. hospitals each year. Only a small fraction of these patients will ultimately be diagnosed as having a heart attack or needing some medical intervention to ward off an imminent attack. The challenge for those of us who see these patients is to determine which patients are in danger of having a heart attack and which can be safely discharged home.

Testing for heart attack
Currently available tests such as electrocardiography (EKG) and blood tests for biomarkers such as troponin are limited in their impact on making “rule-out” decisions in the ED. This decision process often takes from eight to 24 hours and may cost thousands of dollars. The availability of new, highly sensitive tests to detect cardiac ischemia, which is usually caused by clogged arteries, and leads to insufficient oxygen and in severe cases damage to heart muscle, will have a significant impact on how we practice in the emergency department.

Our problem is that the widely available blood tests we have currently are only helpful when someone is actively having or has already had a heart attack. There has been a lot of research activity in the last few years exploring biomarkers such as C-reactive protein, ischemia modified albumin (IMA) and now myeloperoxidase that may help us predict risk more accurately.

When we have more data, these diagnostic markers may become the holy grail of predicting heart attack risk. At this point, however, the MPO test is purely investigational. It will take many more studies involving thousands of patients before we can determine if this test and others currently being studied should become standard medical practice.

Evaluating chest pain
At Yale-New Haven Hospital’s ED, we see about 500 patients with chest pain each month. We currently have three diagnostic tools available to assess the likelihood one of these patients is at risk for an acute cardiac event:

• EKGs, which measure the electrical activity of the heart;
• Biomarkers of cardiac tissue death such as troponin; and
• A history and physical exam to observe physical condition and identify cardiac risk factors such as obesity, smoking, family history and diabetes.

Using these tools, we can quickly diagnose and admit a small percentage of patients as having a heart attack. We can consider for discharge another small percentage of patients based on history and physical findings.

The largest group of patients fall in the “gray” zone. They are experiencing symptoms serious enough to warrant closer examination. We see five to six of these patients in the Yale-New Haven Chest Pain Center every day.

Patients in the Chest Pain Center undergo a series of EKGs and blood tests over six hours. If these tests are normal, we then administer either a chemical or physical exercise stress test. If the stress tests are normal, patients are discharged. About 15 percent of our patients either do not pass the stress tests or have inconclusive results. We admit them for further testing or for an angioplasty in the cardiac catherization laboratory.

Looking for a better predictor
How would a test for MPO be helpful? Rather than waiting six hours to do a stress test, we might hypothetically wait three hours and do an MPO test. If that test indicates little to no risk, we might discharge at that point rather than subjecting the patient to further time and expense for additional testing. If the test indicates a high risk, we would refer these patients for more followup work.

Once we have conclusive data about MPO, it could be very helpful for the large number of people who fall in the gray zone in which emergency physicians must weigh the trade-offs of accelerating treatment versus ‹watchful waitingþ and additional diagnostic testing. It could represent a fourth diagnostic tool to rule out active cardiac syndrome in low-risk patients.

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Dr. Weihl is codirector of the Yale-New Haven Hospital Chest Pain Center and an assistant professor of surgery and internal medicine at the Yale University School of Medicine.