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Arch Intern Med. 2006 Nov 13;166(20):2237-43.

Missed opportunities in the primary care management of early acute ischemic heart disease.

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Division of General Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02120, USA.



The role of primary care clinicians (physicians, nurse practitioners, and physician assistants) in evaluating acute cardiac ischemia is not well documented in office-based settings. Decision aids developed in the emergency department and other settings may help identify missed opportunities to intervene in symptomatic outpatients before hospitalization for acute myocardial infarction.


We conducted a case-control study of patients with no history of heart disease in a multisite group practice. Cases ("missed opportunities") were outpatients evaluated by primary care clinicians for chest pain or other anginal equivalents within 30 days of hospitalization for acute myocardial infarction and not referred for immediate hospital care (n = 106). We identified 3 control patients matched to each case (n = 318) using initial symptom and encounter date. We assessed the ability of several coronary risk prediction tools to identify missed opportunities.


We identified 966 acute myocardial infarction hospital admissions among nearly 250,000 adults, including 261 (27.0%) with qualifying office visits in the preceding 30 days and 106 (11.0%) who were not directly referred for hospital care (cases). Chest pain (50.0%) and dyspnea (26.4%) were present in most of these cases. A Framingham risk score of 10% or greater was associated with missed opportunities (odds ratio, 19.5; 95% confidence interval, 9.3-40.6). Increased scores using the Diamond and Forrester probability and the Goldman prediction tool were also associated with missed opportunities.


Primary care clinicians play an important role in the management of acute cardiac ischemia. The Framingham risk score can help identify missed opportunities that warrant more intensive evaluation.

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