The first ECG has a low sensitivity for myocardial infarction in patients with chest pain
Date First Published:
March 1, 2000
Last Updated:
November 21, 2001
Report by:
Doug Speake, Medical Student (Manchester Royal Infirmary)
Search checked by:
Polly Terry, Manchester Royal Infirmary
Three-Part Question:
In [patients presenting to the ED with cardiac-sounding chest pain] what is the [sensitivity] of the [initial 12 lead ECG]?
Clinical Scenario:
A 55-year-old man with cardiac-sounding chest pain presents to the emergency department. The first ECG is normal. Just before you discharge him you stop to wonder what the sensitivity of the initial 12 lead ECG is in predicting acute myocardial infarction.
Search Strategy:
Medline 1966-09/00 using the OVID interface.
Search Details:
[(exp myocardial infarction OR myocardial infarction.mp OR AMI.mp OR MI.mp) AND (exp electrocardiography OR electrocardiogram.mp OR ECG.mp OR EKG.mp) AND (initial.mp OR first.mp OR single.mp or premier.mp)] AND maximally sensitive diagnostic study filter LIMIT to human and english.
Outcome:
543 papers were found, out of which 533 were irrelevant or of insufficient quality. The remaining 10 papers are shown below.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| First Electrocardiogram in recent Myocardial Infarction. Mc Guiness JB, Begg TB, Semple T. 1976, Scotland | 898 patients admitted to CCU. 400 with AMI. | Prospective diagnostic cohort | Sensitivity of initial ECG | 51% | |
| The Initial Electrocardiogram During Admission for Myocardial Infarction. Use as a predictor of clinical course and facility utilization. Starck ME and Vacek JL. 1987, USA | 221 ED chest pain patients. 39 with AMI. |
Prospective diagnostic cohort | Sensitivity of initial ECG | 62% | Air force hospital, possible selection bias No raw cardiac enzyme data confirming how AMI was diagnosed |
| Early peak of creatine kinase MB in acute myocardial infarction with a nondiagnostic electrocardiogram. Sharkey SW, Apple FS, Elsperger KJ, et al. 1988, USA | 34 patients admitted to CCU. 34 with AMI. |
Prospective diagnostic cohort | Sensitivity of initial ECG | 61% | CCU population not ED Small population size |
| Clinical Characteristics and Outcome of Acute Myocardial Infarction in Patients with Initially normal or Non-specific Electrocardiograms. Rouan GW, Lee TH, Cook EF et al. 1989, USA | 918 ED chest pain patients. 811 with AMI. | Prospective diagnostic cohort | Sensitivity of initial ECG | 13% | Interrator agreement of ECG interpretation not measured from separate participating ED Inclusion of AMI and ischaemic ECG changes |
| Initial ECG in Q wave and Non-Q wave Myocardial Infarction. Fesmire FM, Percy RF, Wears RL, et al. 1989, USA | 440 ED chest pain patients. 100 with AMI. |
Prospective diagnostic cohort. | Sensitivity of initial ECG | 47% | No evidence of timing of the initial ECG |
| Acute Myocardial Infarction in Chest Pain Patients with Non-diagnostic ECGs: Serial CK-MB Sampling in the Emergency Department. Gibler WB, Young GP, Hedges JR, et al. 1992, USA | 616 ED chest pain patients. 108 with AMI. | Prospective diagnostic cohort | Sensitivity of initial ECG | 36% | Recruitment criteria unclear Unclear if series or selection of patients recruited |
| Assessing the Diagnostic Value of an ECG Containing Leads V4r, V8 and V9: The 15 lead ECG. Zalenski RJ, Cooke D, Rydman R, et al. 1993, USA | 149 ED chest pain patients. 34 with AMI. |
Prospective diagnostic cohort. | Sensitivity of initial ECG | 47.10% | Small population |
| The role of Single ECG, Creatinine Kinase and CKMB in diagnosing patients with acute chest pain. Young GP and Green TR. 1993, USA | 222 ED chest pain patients. 43 with AMI. |
Retrospective survey | Sensitivity of initial ECG | 28% | Retrospective study Study population mostly elderly |
| Utility of the Prehospital Electrocardiogram in Diagnosing Acute Coronary Syndromes: The Myocardial Infarction Triage and Intervention (MITI) Project. Kudenchuk PJ, Maynard C, Cobb LA, et al. 1998, USA | 3027 ED chest pain patients. 1149 with AMI. |
Prospective diagnostic cohort | Sensitivity of initial ECG | 69% | Initial ECG taken by paramedics, not in ED |
| Usefulness of Automated Serial 12-Lead ECG Monitoring During the Initial Emergency Department Evaluation of Patients With Chest Pain. Fesmire FM, Percy RF, Bardoner, JB et al. 1998, USA | 1000 ED chest pain patients. 204 with AMI. | Prospective diagnostic cohort | Sensitivity of initial ECG | 55.40% | ?34 patients had AMI following admission to ED |
Author Commentary:
At presentation history, clinical findings and ECG are all that are available to aid clinicians in the diagnosis of AMI. These studies have shown that the first ECG is between 13-69% sensitive for AMI.
Bottom Line:
The first ECG is not sensitive enough to rule out AMI in the Emergency Department.
References:
- Mc Guiness JB, Begg TB, Semple T.. First Electrocardiogram in recent Myocardial Infarction.
- Starck ME and Vacek JL.. The Initial Electrocardiogram During Admission for Myocardial Infarction. Use as a predictor of clinical course and facility utilization.
- Sharkey SW, Apple FS, Elsperger KJ, et al.. Early peak of creatine kinase MB in acute myocardial infarction with a nondiagnostic electrocardiogram.
- Rouan GW, Lee TH, Cook EF et al.. Clinical Characteristics and Outcome of Acute Myocardial Infarction in Patients with Initially normal or Non-specific Electrocardiograms.
- Fesmire FM, Percy RF, Wears RL, et al.. Initial ECG in Q wave and Non-Q wave Myocardial Infarction.
- Gibler WB, Young GP, Hedges JR, et al.. Acute Myocardial Infarction in Chest Pain Patients with Non-diagnostic ECGs: Serial CK-MB Sampling in the Emergency Department.
- Zalenski RJ, Cooke D, Rydman R, et al.. Assessing the Diagnostic Value of an ECG Containing Leads V4r, V8 and V9: The 15 lead ECG.
- Young GP and Green TR.. The role of Single ECG, Creatinine Kinase and CKMB in diagnosing patients with acute chest pain.
- Kudenchuk PJ, Maynard C, Cobb LA, et al.. Utility of the Prehospital Electrocardiogram in Diagnosing Acute Coronary Syndromes: The Myocardial Infarction Triage and Intervention (MITI) Project.
- Fesmire FM, Percy RF, Bardoner, JB et al.. Usefulness of Automated Serial 12-Lead ECG Monitoring During the Initial Emergency Department Evaluation of Patients With Chest Pain.