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For Release After 10 a.m. CST, Tuesday, Dec. 2, 1997

MISDIAGNOSIS OF HEART ATTACK IN THE E.R. CAN BE REDUCED AND HEALTH CARE DOLLARS SAVED WITH PROMPT RADIOLOGY EXAMS

CHICAGO -- The misdiagnosis of heart attack and other life-threatening conditions in emergency rooms can be dramatically decreased and millions in health care dollars saved by performing prompt radiologic imaging of patients with chest pain before they are admitted to the hospital. Information on the topic was presented here today during the 83rd Scientific Assembly and Annual Meeting of the Radiological Society of North America (RSNA).

"The misdiagnosis or 'under-diagnosis' of heart attack is a serious and costly problem," said Jack A. Ziffer, M.D., Ph.D. "Typically, from 3 percent to 5 percent of heart attack patients are misdiagnosed and sent home from emergency rooms each year in the United States. On the other hand, as many as 70 percent of all patients with chest pain are not having heart attacks, and a great number of them are needlessly admitted to the hospital," he said. Dr. Ziffer is director of cardiac imaging, Miami Cardiac and Vascular Institute; and medical director, nuclear medicine and PET, Baptist Hospital, Miami.

"By offering prompt radiologic imaging before admission, we reduced the number of misdiagnosed heart attacks to less than two-tenths of 1 percent. With this approach, we reduced misdiagnoses and saved $5.2 million over 18 months in just this one hospital, compared to the conventional approach that requires inpatient evaluation," he said.

Approximately 25 percent of the 4 million people who come to the nation's emergency rooms complaining of chest pain each year are having a heart attack or are on the verge of having a heart attack, 5 percent have other life-threatening conditions such as pulmonary emboli (blood clots in the lung) or aortic dissection (a rare, life-threatening condition in which the innermost lining of the aorta, the body's largest blood vessel, peels away from the vessel wall). The remaining 70 percent have gastrointestinal disease such as gallstones or hiatal hernia, or musculoskeletal abnormalities such as broken ribs.

"The goal of the emergency room physician is to decide very quickly what is causing the patient's pain. By providing radiologic imaging in the emergency department 24 hours a day, we can rapidly diagnose or rule out heart attacks or other dangerous conditions," Dr. Ziffer said.

Dr. Ziffer reported results of 4,280 patients who were evaluated in the chest pain center over an 18-month period. A total of 88 percent (3,766) were discharged without hospitalization. The average length of stay in the emergency room was 12 hours. Depending on the patient's clinical symptoms, one or more of the following radiology tests were performed: conventional chest x- rays; single-photon emission computed tomography (SPECT) -- a nuclear medicine test that is used to measure blood flow to the heart; magnetic resonance (MR) imaging; ultrasound (US); computed tomography (CT); and ventilation-perfusion (VQ) scans -- tests performed to detect blood clots in the lungs.

Virtually all patients (nearly 99 percent) had a chest x-ray and electrocardiogram (ECG). They were evaluated by specially trained emergency room personnel and placed in one of four categories:

ï Those who were known to be having a heart attack based on ECG and patient history -- approximately 10 percent of all patients. These patients were referred immediately for treatment without further testing.

Patients in other categories who were referred for further radiologic imaging included: ï Patients thought to have other cardiovascular problems, such as pulmonary emboli or aortic dissection.

ï Patients thought to have gastrointestinal or musculoskeletal conditions.

ï Patients who were suspected of having heart attack or a pending heart attack but who had normal ECGs. "This group of 2,737 patients -- nearly two-thirds of all patients -- had SPECT imaging to assess the flow of blood to the heart," Dr. Ziffer said. Of these, 77 percent were found to have normal heart function and were discharged. "Despite intensive use of radiology services, the overall cost of patient care was reduced by $5.2 million in this group alone," he said.

"The SPECT scan takes a lot of worry out of deciding which patients can be safely discharged," said David Nateman, M.D., director of the Chest Pain Center. "As a result, I'm able to sleep better at night."

In addition to improved diagnoses, other advantages of offering prompt radiologic imaging in a dedicated chest pain center include:

ï There are fewer hospital admissions. "Before we opened the Chest Pain Center and made radiologic imaging immediately available, about 40 percent of patients with chest pain were admitted to the hospital. Now, only about 12 percent of patients require admission," said Dr. Ziffer.

ï Outpatient diagnostic imaging can decrease overall lengths of hospital stay. "Before, the average length of stay was 1.9 days -- including patients who turned out not to require hospitalization," Dr. Ziffer said. "The average length of stay after we opened the Chest Pain Center increased only modestly to 2.3 days, because the patients admitted were much sicker," he said. "This is because many of the needed diagnostic tests are done before admission. We don't have situations where, say, a patient is admitted on a Friday and then has to wait until Monday to have diagnostic testing done."

ï It frees up needed beds in the hospital. "Someone with a suspected heart attack has to be monitored with ECG around the clock. This requires a special setting with 'telemetry beds,' which typically are in short supply," Dr. Ziffer said. When telemetry beds are not available, patients may have to be monitored in the intensive care or cardiac care unit, which can dramatically drive up costs, he said.

The Chest Pain Center is located in the same area as the hospital emergency room, Dr. Nateman said. Patients who come to the hospital complaining of chest pain are evaluated in the emergency room and referred to the center when appropriate.

Co-authors of a paper on the topic presented by Dr. Ziffer during the RSNA meeting are W. Janowitz, M.D.; N. Messinger, M.D.; C. Sperrazza, R.N.; L. Bellmas, C.N.M.T.; and D. Nateman, M.D.

The RSNA is an association of 30,000 radiologists and physicists in medicine dedicated to education and research in the science of radiology. The Society's headquarters are located at 2021 Spring Road, Suite 600, Oak Brook, Illinois 60523-1860.

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Copies of 1997 RSNA news releases are available online at http://www.pcipr.com/rsna beginning Monday, Dec. 1.