The recognition of acute coronary ischemia in the outpatient setting

Background: The missed diagnosis of acute myocardial infarction has been studied in the Emergency Department, but few studies have investigated how often coronary ischemia is correctly identified in the outpatient setting. Methods: This was a single center retrospective observational study of patients with Health Alliance Plan medical insurance hospitalized at a US tertiary center with acute myocardial infarction in 2004. Outpatient encounters in the 30 days preceding acute myocardial infarction were reviewed by two independent cardiologists for presenting symptoms and diagnostic decision-making in order to classify patient presentations as acute coronary ischemia, stable angina or neither. Results: There were 331 patients with acute myocardial infarction, including 190 (57%) with a primary diagnosis of AMI and evaluated by a physician in the preceding 30 days. This group included 68 patients with 95 documented outpatient encounters by a primary care physician, cardiologist, or other internal medicine specialist which formed the final study population. Mean interval between these encounters and AMI was 17 ± 11 days. Of these patients, 7 (10%) had symptoms of acute coronary ischemia, 5 (7%) had stable angina symptoms, and 56 (83%) had no symptoms of coronary ischemia at their outpatient encounters. Of the 7 patients with acute coronary ischemic symptoms, 5 were correctly identified and 2 were misidentified. Conclusion: A majority of patients with subsequent AMI visit an outpatient provider in the month preceding AMI. However, few present with symptoms of coronary ischemia in the outpatient setting (10%) and these symptoms are not always identified as such.