Which acute MI patients are most at risk for mistriage? Identify them

Look beyond 'typical' symptoms of ED patients

A female patient told ED nurses that her only complaint was back pain, with no shortness of breath, chest pain, discomfort, nausea, or vomiting.

"There was no history of acute coronary syndrome, and no family history to support a suspicion of cardiac origin. Only because the EKG was done for admission did the team learn that there was an active STEMI [ST-elevation myocardial infarction] present," recalls Patrick L. Evangelista, RN, who cared for the patient at an ED where he worked previously. Evangelista is an ED nurse at Kaiser Permanente's Moanalua Medical Center in Honolulu, HI.

Certain acute myocardial infarction (AMI) patients are more likely to be mistriaged as low acuity, according to a new study. These are the elderly, women, and diabetics.1

Clare Atzema, MD, the study's lead author and a scientist at Sunnybrook Health Sciences Centre in Toronto, Ontario, Canada, says, "The triage process is necessarily brief. Even after a full ED work-up, between 2% and 5% of AMI patients are missed and sent home."

Evangelista says that one obvious problem for emergency nurses is "limited time to look at the whole picture of what is going on in that particular moment. Subtleties of symptoms can be overlooked as nursing focuses on the dramatics of a full ED, lobby, or waiting area, and a backup of ambulance rigs wanting bed space as well as nursing time."

Atzema acknowledges, "It is a tough job to identify these patients at triage. It will never be perfect. That said, it is a big opportunity to affect lives."

To improve your assessment of AMI, make these changes:

• Get as much practice as possible.

Evangelista says you should "look at EKG after EKG, even if it's someone else's patient."

EDs that saw high volumes of AMI patients triaged them more accurately than those with low volumes, according to the study. Atzema says, "Practice makes perfect, or as close to it as you can get. The more chest pain patients you see, especially those that turn out to be experiencing an AMI, the better you will become at recognizing and triaging them."

• Find out what happened to your ED patients.

Atzema recommends taking the time to see which patients discharged from your ED were eventually diagnosed with an AMI.

Medical records of AMI patients are reviewed by ED nurses at Massachusetts General Hospital in Boston, reports Jeffery Chambers, RN, an ED nurse and member of the STEMI committee. "Feedback is given directly to the nurses involved in the patient's care," Chamber says.

• Probe deeper if patients report vague complaints.

Chambers says that patients who downplay their symptoms or withhold information, such as cocaine use, put themselves at risk. "Patients who are poor historians and have difficulty describing the events are also vulnerable," he says. "Triage nurses must probe deeper in those patients who present with vague complaints."

Chambers says that in his experience, it's not unusual that further questioning leads to a diagnosis of an MI.

Always get an EKG done right away, even if the patient isn't having or hasn't experienced chest pain.

Atzema says, "Elderly patients, women, and diabetic patients often won't have chest pain. If you get an early EKG on these patients, then you won't miss any STEMIs, where delays in terms of minutes really matter. Even just capturing those patients would affect a substantial change in mortality rates."

• Look at the "big picture."

Evangelista says to "look beyond the typical MI symptom and see the patient holistically. We need to be able to reason through differential possibilities, and not just perform task nursing."

Notice these details, advises Evangelista: Whether the patient is obese, presents with shortness of breath on exertion, is pale, is diaphoretic, is holding their arm or chest, whether they smell of cigarettes, the temperature of their skin, and even whether they have on a wedding band. "We can use all this information to evaluate the patient," says Evangelista. Identifying risk factors can make a strong case for expediting the patient to a bed, an EKG and blood draw, he explains.

"An obese patient is more likely to have a heart attack then someone who is not," says Evangelista. The wedding band can be indicative of risk of MI. Married female patients statistically have a greater risk of dying of a heart attack than an unmarried woman, and conversely for men." (See related stories on determining whether a patient's symptoms are cardiac and recommended triage practices, below.)


  1. Atzema CL, Austin PC, Tu JV, et al. ED triage of patients with acute myocardial infarction: predictors of low acuity triage. Am J Emerg Med 2010;28:694-702.


For more information on assessment of myocardial infarction, contact:

  • Clare Atzema, MD, Sunnybrook Health Sciences Centre in Toronto, Ontario, Canada. Phone: (416) 480-6100, Ext. 83784. E-mail: clare.atzema@ices.on.ca.
  • Jeffery Chambers, RN, Emergency Department, Massachusetts General Hospital, Boston. E-mail: jechambers@partners.org.
  • Eric Joncas, RN, Patient Care Supervisor, Emergency Department, Fairview Southdale Hospital, Edina, MN. Phone: (952) 924-8307. E-mail: ejoncas1@fairview.org.

Clinical Tips

Are patient's symptoms cardiac? Ask why not

Eric Joncas, RN, patient care supervisor in the ED at Fairview Southdale Hospital in Edina, MN, considers any presenting complaint that is above the waist to be cardiac, and then he asks targeted questions to prove that it isn't.

"Women in particular often present with vague atypical symptoms that often steer the triage or ED nurse down the wrong path," notes Joncas. "It is because of this that I have adopted the approach of asking 'How or why isn't this cardiac?'"

Joncas considers the patient's description of onset, duration, quality, and radiation, as well as past medical history, a brief medication history, and overall physical appearance "for that gut instinct." He asks himself whether he is fully convinced that the complaint isn't cardiac. "If all of the above is not enough to convince me, I do the EKG and have it read by an ED physician," he says.

Use these triage practices for MI

Lack of education regarding the signs and symptoms of myocardial infarction (MI) and failing to provide interpreter services quickly upon presentation are two reasons why an MI might be missed by a busy ED nurse, according to Jeffery Chambers, RN, an ED nurse and member of the STEMI committee at Massachusetts General Hospital in Boston. Here are the ED's triage practices:

• As soon as a patient enters the ED, he or she is seen by an experienced ED nurse who greets the patient.

After a 30-second to 2-minute interview, the nurse greeter determines the immediate need to send the patient directly to an acute treatment area, receive an EKG, or have the patient go to a triage desk to complete the normal triage process, says Chambers.

Patients sent to the acute treatment area skip the normal triage process, receive an EKG, and are immediately evaluated, says Chambers.

• If the nurse greeter decides an EKG is needed to help determine a patient's acuity upon arrival, he or she asks a patient care associate (PCA) to perform the EKG.

The PCA immediately escorts the patient to a stretcher, located only a few steps from the triage area, and performs the EKG. "With the patient still lying on the stretcher, the EKG is handed directly to an ED attending physician," says Chambers. "The attending doctor reads the EKG and determines the level of acuity."

• If there is any suspicion of an acute cardiac issue, the patient is taken directly to the acute treatment area.

If there is no immediate life-threatening concern, patients will finish the triage process. "The latter group of patients will be evaluated by a physician within 30 minutes of arrival in the screening bays," says Chambers.

Expect vague symptoms

Remember that AMIs present without chest pain in one-third of patients, says Clare Atzema, MD, a scientist at Sunnybrook Health Sciences Centre in Toronto, Ontario, Canada. Atzema says to always consider the possibility of an AMI in an elder, woman or diabetic with weakness or shortness of breath.

"Triage them according to your clinical suspicion," she says.

Patrick L. Evangelista, RN, an ED nurse at Kaiser Permanente's Moanalua Medical Center in Honolulu, HI, notes that not all MI patients experience a crushing chest pain radiating to the jaw and left arm with diaphoresis, shortness of breath, and/or nausea and vomiting.

"Some symptoms are 'silent' and nonspecific to a cardiac origin," he says. "Men and women present differently with AMI symptoms. Women who have a first time acute coronary syndrome show a wider range and more atypical symptoms compared to men."

Female symptoms might include generalized fatigue, indigestion, and/or mild to moderate shortness of breath, says Evangelista. "Many times a woman having an AMI may be overlooked both based on the patient's chief complaint as well as presentation to the ED," he says.

Elderly might have different symptoms than younger patients and might present only with shortness of breath, weakness, syncope or near-syncope, diaphoresis, and nausea or vomiting, says Evangelista.

Chambers notes that "typical signs and symptoms of an MI are more obvious and easy to detect," such as chest pain, pressure, or discomfort that radiates to the neck, jaw, back, or arms. In reality, though, MI patients might present with abdominal pain, nausea and vomiting with or without pain, weakness, dizziness, shortness of breath, heartburn, and general malaise or fatigue, he adds.

Evangelista says that "atypical is typical. No one is absolutely typical. Don't waste time trying to find that one thing that will let you avoid doing a full work-up."