[Leading symptoms of chest pain in the emergency room. Using cardiac markers for risk stratification].

BACKGROUND AND OBJECTIVE: The acute coronary syndrome (ACS)--acute infarction or unstable angina pectoris--requires special monitoring and differentiated treatment. A prospective trial was undertaken to determine (1) clinical characteristics of patients with chest pain; (2) value of cardiac markers troponin T, myoglobin and CK-MB mass in differentiating cardiac and noncardiac chest pain; (3) the proportion of patients with ACS in whom these markers provided helpful additional information on admission and afterwards.

PATIENTS AND METHODS: 233 consecutive patients (134 men, 99 women; aged 18-98 years), presenting in 1998 with nontraumatic chest pain at the emergency unit of the Lippe-Detmold Hospital were prospectively enrolled in the study. Levels of troponin T, myoglobin, CK-MB mass and activity and creatine kinase were measured on admission and after 2, 4 and 12-24 hours.

RESULTS: ACS was ultimately diagnosed in 73 patients (31%). These were significantly older (p = 0.0015) and more often male (p = 0.046). 91% of patients with ACS but only 68% of those without described the chest pain as a sense of pressure or stabbing (p = 0.0002). Measurement of troponin T and myoglobin on admission was helpful in 39% of those with ACS, compared with 15% of those without. When the admission ECG was normal or nonspecific in patients with ACS, troponin T was elevated in 16%, CK-MB mass in 24%. In patients with unstable angina no single marker was associated with an increased risk (high rate of special supervision and intervention).

CONCLUSION: In the assessment of patients with acute chest pain clinical judgement plays the predominant role. In the mostly elderly and male patients with ACS (31% of the cohort) feeling of pressure or stabbing chest pain were most prominent (91%). Cardiac markers troponin T, CK-MB mass and myoglobin were helpful in the differential diagnosis of chest pain, even when the ECG was unremarkable or nonspecific. At the time of admission myoglobin was the most significant marker for acute myocardial infarction or unstable angina.