Approach To Low Probability Of Ischemia

After initial evaluation, early data collection, and interpretation, a high potential for the presence of an ACS will be recognized in many patients. The approach to further risk stratification and treatment of these patients is detailed in Chap.47. Many others can be classified as having a low probability of acute ischemia based on clinical information available at the time of their ED visit. However, there is currently no consensus in the literature on their optimal management or even a widely accepted definition of who belongs to this group. There is consensus on two issues: that history alone is inadequate to exclude the presence of acute ischemia and that the goal must be "zero tolerance" for missed AMI.23 A systematic approach based on objective data is required to identify these lower-risk patients early in their course (Jable,„45-4) while also resulting in lower costs and, perhaps, improved outcomes ( Fig.45-3).

if Pr-kpU-1 s----1 Mnria +T»!- iW -— «4-iri-r f-traia

■s.■■ Bir f! T- itnj im■!!!■!nir . nkm■ btt■— ■ hi if Pr-kpU-1 s----1 Mnria +T»!- iW -— «4-iri-r f-traia

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TABLE 45-4 Proposed Prognosis-Based Classification System for ED Chest Pain Patients*

FIG. 45-3. Algorithm for risk-based decision making.

Diagnostic tools now available for this group of patients include myocardial marker measurements (see above), stress testing, nuclear or ultrasound imaging, and advanced monitoring techniques. A description of the commonly used approaches for low-risk patients follows.

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