New JAMA Article Reviews Rationale Approach to Chest Pain Evaluation

Author’s from Duke University recently published an outstanding systematic review in JAMA investigating the evidence behind rationale chest pain evaluation. Accurate estimation of the probability of ACS in patients is essential. Using a well reasoned clinical examination could prevent many hospital admissions among low-risk patients and ensures that high-risk patients are promptly treated. 58 unique studies were examined to determine the sensitivity, specificity, and likelihood ratio (LR) of findings associated with the diagnosis of ACS. The article provides comprehensive tables listing the diagnostic fortitude of various historical, physical exam and imaging  features.

The clinical findings and risk factors most suggestive of ACS were prior abnormal stress test (specificity, 96%; LR, 3.1 [95%CI, 2.0-4.7]), peripheral arterial disease (specificity,97%; LR, 2.7 [95%CI, 1.5-4.8]), and pain radiating to both arms (specificity, 96%; LR, 2.6 [95%CI, 1.8-3.7]). The most useful electrocardiogram findings were ST-segment depression
(specificity, 95%; LR, 5.3 [95%CI, 2.1-8.6]) and any evidence of ischemia (specificity, 91%; LR, 3.6 [95%CI,1.6-5.7]). Taken together, among patients with suspected ACS, the initial history, physical examination, and electrocardiogram alone did not confirm or exclude the diagnosis of ACS. Instead, the HEART or TIMI risk scores, provided more diagnostic information.

This article is certainly worth saving as it provides high quality reports of sensitivity, specificity and liklihood ratios for ACS diagnostic elements. These features are essential when managing the borderlin “ACS rule out” patient in the CCU or on the Wards.