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March 26, 1997

The AHCPR Unstable Angina Algorithm in Practice-Reply

Author Affiliations

University of Wisconsin Medical School Madison
Tufts University School of Medicine Boston, Mass
Flushing Hospital Medical Center Flushing, NY

JAMA. 1997;277(12):962. doi:10.1001/jama.1997.03540360030016

In Reply.  —We agree with the authors of both letters that the inclusion criteria are critical to both the clinical application and the evaluation of the AHCPR unstable angina guideline. Our data suggest that, among ED patients diagnosed with unstable angina, a very small proportion will be defined as "low risk" by the guideline's criteria. As detailed in our article, we used the Imminent Myocardial Infarction Rotterdam (IMIR) inclusion criteria, which include not only chest pain and the usual chest pain equivalents (chest discomfort, arm pain, neck pain) but also shortness of breath, dizziness, palpitations, and other symptoms suggestive of acute cardiac ischemia. We then restricted our analysis to a broad spectrum of unselected patients with unstable angina, including patients for whom the ED diagnosis of unstable angina was less than certain.The letters also question why our evaluation did not include patients with diagnoses other than unstable angina, such as "rule