Goldman's Algorithm for Chest Pain

Goldman Algorithm for Chest Pain

The history of cardiac care had it's turning point in 2001 when the Goldman's Algorithm was first adopted by a hospital called Cook County in Chicago. What happened that led to this breakthrough?

The churning began a few years earlier in 1995. Cook County was the city’s principal public hospital and famous for harbouring the world’s first blood bank. Also for being the place where cobalt-beam therapy had been pioneered. Of late, however, the hospital was in a mess. With
cavernous wards with no air conditioning, no private room, telephone or cafeteria, with bells ringing all the while due to understaffed nurses, with noisy private TVs and radios of overcrowded patients, it was a crazy place desperately in need of a haul up.

There was another problem. There were 2.5 lakh emergency patients complaining of chest pain in a year. But only 10% of the
patients admitted into the cardiac care were true cases.

In the summer of 1995, the hospital got a new chairman for its department of medicine. He was Brendan Reilly.

Reilly devised specialist protocols for cardiac patients. He segregated the cardiac patients into three groups and sent them accordingly to an
8-bed cardiac coronary care, a 12-bed intermediary care and an observation unit.

If a patient would complain of chest pain, the doctor would put a stethoscope and listen for the crinkling sound of fluid in the lungs (meaning heart is not able to pump). Then the doctor would place electrodes on the patient’s chest, arms and legs and print an electrocardiogram or ECG on a pink graph paper. A consistent ECG or an
"even mountain range" would mean a healthy heart. But if a normally climbing slope was found plunging, or a usual curve was found flat, elongated or spiked, that meant trouble.

However, the protocol was elaborate and procedure inaccurate and, therefore, a doctor would make an informed estimate and admit the patient, often erring on the side of caution. After the admission the patient would undergo a series of tests for particular enzymes after which treatment would begin.

For a systematic solution, Reilly therefore turned to Lee Goldman, a renowned cardiologist who had found that mathematical principles can be used to decide whether some was suffering from myocardial infarction (heart attack in common parlance). He had fed hundreds of factors into a computer and founded a
predictive algorithm. The primary step was whether the ECG showed acute ischemia
(heart muscle not getting blood supply). After the first step, three risk factors were evaluated - pain (is the pain unstable angina?), fluid (is there fluid in the patient’s lungs?) and BP (is the systolic
pressure below 100?). With the help of these factors in various combinations, Goldman created a decision tree.

A patient with normal ECG with all three positive factors  got intermediary care
A patient with abnormal ECG with one or no positive factors went to the observation unit. A patient with abnormal ECG with two or three positive factors was put in the CCU.

This decision tree had not been adopted by any reputed medical school till then. Before Reilly adopted it, it was the Pentagon which had funded Goldman’s research as they were in dire need to know whether a US submarine should surface (and become exposed) if it had a sailor suffering from chest pain.

Before implementing Goldman’s algorithm, Reilly sampled 20 typical cardiac histories of people with chest pain and gave them to cardiologists, internists, ER docs and medical residents for their estimate of whether the patients would suffer a “heart attack” in the next three days. The estimates varied over a range of 0 - 100%.

Emboldened by this variance, Reilly alternately employed traditional evaluation and Goldman’s algorithm for two years. At the end of it, Goldman’s rule won hands down by a whopping 70% better rate in terms of accuracy. Even in the case of
the most serious patients, Goldman’s method was 95% accurate against 75 - 89% accuracy of traditional diagnosis.

Today, the heart attack decision tree of Goldman is displayed on the wall at Cook County hospital.

- adapted from the book "Blink" by Malcolm Gladwell