Chest Pain in the ED—What to Do with the Younger Folks?

Abstract & Commentary

Source: Walker NJ, et al. Characteristics and outcomes of young adults who present to the emergency department with chest pain. Acad Emerg Med 2001;8:703-708.

To better characterize the optimal evaluation of younger chest pain (CP) patients, Walker and colleagues studied 487 patients younger than age 40 with acute CP during 527 visits to the emergency department (ED) over a 15-month period at the University of Pennsylvania. Clinical examination, electrocardiograms (ECGs), and cardiac enzyme tests were performed in each case. Patients using cocaine were excluded. ECGs were interpreted by attending ED physicians. Enzymes were interpreted as indicative of acute myocardial infarction (AMI) or unstable angina (USA) if CK-MB exceeded 10 ng/mL or 5 ng/mL, respectively, and/or troponin-I exceeded 2 ng/mL or 0.3 ng/mL, respectively. All patients were followed during ED stays or hospital admission, and were contacted 30 days later and asked if they had experienced any occurrence of acute coronary syndromes (ACS).

Ages ranged from 25 to 40 years, with 71% between the ages of 30 and 39 years. Sixty percent were female, and 73% African American. Forty-two percent had no risk factors for coronary artery disease (CAD), while 37% were smokers and 22% were hypertensive. Pressure-like or squeezing CP was present in 42%, sharp or stabbing CP in 35%, and radiation of pain to the neck or left arm in 31%. Normal or nondiagnostic ECGs were documented in 93% of cases, whereas 5% had early repolarization, 1% had bundle branch block, and 2% had evidence of ischemia or infarction.

During hospital evaluation or at 30-day follow-up, 35 of the 169 patients (21%) had further work-up for CAD, revealing five of 23 stress sestamibi scans that were abnormal and five of 12 coronary angiograms with greater than 70% stenoses. By all criteria available, an ACS (AMI or USA) was documented in a total of 25 patients, for an event rate of 4.7% (95% CI, 2.9-6.5%). Eight patients (1.5%) had AMI, five had percutaneous transluminal coronary angioplasty (PTCA) or stenting, none required coronary artery bypass graft (CABG), and four (0.7%) died—one of cardiac arrest, one with metastatic carcinoma, one with end-stage congestive heart failure, and one with diabetes and end-stage renal failure in a nursing home. Thirty-day survival was 99% for the cohort.

Comment by Michael Felz, MD

The authors conclude that acute CAD-related events are unusual in patients with acute CP who are younger than age 40. They emphasize certain differences in demographics and risk factors for younger patients. For example, 81-94% of AMIs prior to age 40 occur in males.1 Risk factors in younger patients include smoking (62-94%), family history (15-84%), and hyperlipidemia (20-61%), while diabetes is rare (12%).2 At angiography, younger AMI patients usually have single-vessel CAD, while 14-20% of cases have normal coronary anatomy, raising the question of vessel spasm.3

Based on the data in this study, young patients with CP have a 4.7% risk of ACS, including a 1.5% risk of AMI. Taken in obverse, this translates into a 95.3% likelihood that the under-40 CP patient in the ED has no CAD-related event, and a 98.5% chance that AMI is not present. The likelihood of survival of such patients exceeds 99% at 30 days, according to this analysis. My response to this study is three-fold. First, the rarity of ACS in younger patients is consistent with my experience in 23 years of primary care practice and teaching. Costochondritis, reflux, and muscle strain are vastly more common than CAD in this age group. Yet I remain vigilant, remembering a handful of patients younger than age 40, both men and women, who had impressive ST elevation, alarming enzyme levels, greater than 90% stenoses on catheterization, and emergent PTCA or stenting. Thankfully, nearly all recovered rapidly and went to work on risk factor modification. It is noteworthy that the incidence of AMI in cocaine-associated CP has been reported to be 6%,4 a nearly identical rate to that in the current series. Second, the current study evaluated predominantly young, African Amercan females. Whether these data can be extrapolated to the general population is not clear. Finally, I would have been interested in physical exam information on these patients, especially how often focal, reproducable chest wall tenderness was present. This common finding in younger patients, and in older ones as well, is reassuring for exclusion of CAD, especially when the ECG is normal.5

References

1. Fournier JA, et al. Myocardial infarction in men aged 40 years or less: A prospective clinical-angiographic study. Clin Cardiol 1996;19:631-636.

2. Kanitz MG, et al. Myocardial infarction in young adults: Risk factors and clinical features. J Emerg Med 1996;14: 139-145.

3. Negus BH, et al. Coronary anatomy and prognosis of young, asymptomatic survivors of myocardial infarction. Am J Med 1994;96:354-358.

4. Weber JE, et al. Cocaine-associated chest pain: How common is myocardial infarction? Acad Emerg Med 2000;7: 873-877.

5. Felz MW. Costochondritis: Take a scientific stand in the emergency department. Emerg Med Alert 2001;8:5-7.

(Dr. Felz, Associate Professor, Department of Family Medicine, Medical College of Georgia, Augusta, Ga., is on the Editorial Board of Emergency Medicine Alert.)