Prediction of the Need for Intensive Care in Patients Who Come to Emergency Departments with Acute Chest Pain

BACKGROUND: Patients who come to the emergency department with chest pain are a heterogeneous group. Some have ischemic heart disease that may lead to serious complications, whereas others have minor disorders. We performed a study to identify clinical factors that predict which patients will have complications requiring intensive care. METHODS: We first studied 10,682 patients with acute chest pain at seven hospitals between 1984 and 1986 (derivation set) to identify potential clinical predictors of the development of major complications. We then validated these predictors in a separate set of 4676 patients at one hospital between 1990 and 1994 (validation set). RESULTS: In the derivation set of patients, we identified the following set of clinical features, which, if present in the emergency department, were associated with an increased risk of complications: ST-segment elevation or Q waves on the electrocardiogram thought to indicate acute myocardial infarction, other electrocardiographic changes indicating myocardial ischemia, low systolic blood pressure, pulmonary rales above the bases, or an exacerbation of known ischemic heart disease. On the basis of these criteria, the patients in the validation set were stratified into four groups, with the risk of major complications in the first 12 hours ranging from 0.15 to 8 percent. After 12 hours, the probability of a major complication could be updated on the basis of whether the patient had already had a complication of major severity, a complication of intermediate severity, or a myocardial infarction (independent relative risks, 18.9, 7.7 and 4.0, respectively, as compared with patients without prior complications or myocardial infarction). CONCLUSIONS: The risk of major complications in patients with acute chest pain can be estimated on the basis of the clinical presentation and new clinical observations made during the hospital course. These estimates of risk help in making rational decisions about the appropriate level of medical care for patients with acute chest pain.