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

Background: 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. Methods: We conducted a case-control study of patients with no history of heart disease in a multisite group practice. Cases("missedopportunities") were outpatients evaluated by primary care clinicians for chest pain or other anginal equivalents within 30days 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. Conclusions: 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.