The ECG may help to identify nonischemic causes of chest pain such as dysrhythmias, acute pericarditis, or pulmonary embolism.

Because of the importance of early diagnosis of MI (and hence reduced delay of thrombolytic treatment), specific recommendations have been made concerning the procurement of the initial ECG in the eD. That is, under standing orders, patients with ischemic-type pain should have a 12-lead ECG performed within 10 min of arrival in the ED and the ECG should be handed directly to the treating physician for immediate interpretation. Considering the difficulty of defining "ischemic type" pain and the frequency of atypical presentations, it would be prudent to extend this protocol to all adult patients with chest pain.

Although the ECG is a critical guide to therapy when positive, a normal or nonspecific ECG is not reassuring. Among patients presenting to the ED with AMI, only about half will present with diagnostic changes on the initial ECG. Serial ECGs, even over several hours during the patient's ED stay, will increase the sensitivity of the ECG for the detection of AMI and should therefore be encouraged.7 The inclusion of right-sided, posterior, or 22-lead ECGs can also improve the diagnostic yield and should be considered in all patients with known or suspected ischemia of the inferior, lateral, or posterior walls or of the right ventricle. 8 The use of continuous 12-lead ST-segment monitoring in the ED may also aid in the detection of patients with transient and/or silent ischemia.

Risk stratification based on the initial ED ECG has also been suggested as a way of improving ED decision making. Although the initial ECG cannot exclude AMI, stable ED patients whose initial ECG is without ischemic changes are at low risk of subsequent life threatening complications and can usually be managed in a non-intensive-care setting.9

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