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As the most common cause of death in this country, acute myocardial infarction (AMI) has deservedly been the subject of substantial efforts of clinicians, scientists, governmental and other agencies, and the public in efforts to reduce its devastating impact. Although very significant progress continues to be made, The National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (NIH) recognized the need for a concerted and coordinated effort to reduce mortality and morbidity

From: Contemporary Cardiology: Management of Acute Coronary Syndromes, Second Edition Edited by: C. P. Cannon © Humana Press Inc., Totowa, NJ

in this country from AMI and, in 1991, initiated the National Heart Attack Alert Program (NHAAP).

Detecting AMI and unstable angina pectoris (UAP) in the emergency department (ED) is a most challenging task, and the consequences of a missed diagnosis can be very detrimental to both patients and physicians alike. The high prevalence of disease and resulting common, atypical presentations, and the poor sensitivity or specificity of the clinical exam have led to the use of many technologies to assist in establishing an accurate diagnosis. Recognizing this central and growing role of diagnostic technologies for AMI and for acute cardiac ischemia (ACI) in general (including both UAP and AMI) in emergency settings, which represent patients' entry points into the health care system, the NHAAP Working Group on Evaluation of Technologies for Identifying Acute Cardiac Ischemia in the Emergency Department was formed in 1994 (1,2) to assess the utility of diagnostic technologies for ACI/AMI in the ED. A systematic assessment of the literature commenced in 1998 (3-6). This update, termed the Systematic Review, was performed by the New England Medical Center Evidence-based Practice Center under contract to the Agency for Healthcare Research and Quality, Rockville, Maryland. This chapter utilizes the assessments of the Systematic Review on the diagnostic performance and impact on care of those technologies and updates its base of scientific evidence. The technologies reviewed address the diagnosis of ACI (i.e., both AMI and UAP), as this is the condition that must be identified in the treatment of patients with AMI and potential AMI. The review included technologies directed at the diagnosis of ACI in the ED; methods primarily directed at prognostic or risk stratification of such patients are not addressed.

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