Chest Pain History
Chest Pain: Critical Elements of a Patient History
Take Home Points
Clinical factors that INCREASE likelihood of ACS/AMI:
- CP radiating bilaterally > right > left
- Diaphoresis associated with CP
- N/V associated with CP
- Pain with exertion
Clinical factors that DECREASE likelihood of ACS/AMI: Chest pain that is:
- Pleuritic
- Positional
- Sharp, stabbing
- Reproducible with palpation
Severity of pain is not related to likelihood of AMI at presentation, or composite end points (death, revascularization, or AMI) at 30 days
Objective:
- Determine any correlation between severity of CP and the risk of AMI at presentation, or composite end points (death, revascularization, or acute myocardial infarction) at 30 days
- Severe CP was defined as 9–10 on a 10-point pain scale.
Results: (n=3,306)
- Risk of AMI with Pain Score of 1–8 (82% of patients) = 3.0%
- Risk of AMI with Pain Score of 9–10 (18% of patients) = 3.9%
- Not statistically significant different
Many “atypical” symptoms are more likely to render the diagnosis of ACS than traditional “typical” symptoms
Objective:
- Assess the value of individual symptoms for predicting a diagnosis of AMI or the occurrence of adverse events (death, AMI, revascularization via PCI or CABG) within 6 months
Results: (n=796)
- Strongest positive predictor of AMI:
- Diaphoresis with CP
- Other positive predictors of AMI and adverse events
- Nausea and vomiting with CP
- CP with radiation to both shoulders > right shoulder > left shoulder
- Central chest pain
- Strongest negative predictor of AMI
- Pain located in the left anterior chest
- Other negative predictors of AMI and adverse events
- CP described as pain being the same as previous AMI
- Presence of CP at rest
No characteristics of CP alone, or in combination, identify a group of patients that can be safely discharge home without further diagnostic testing
Objective: In a literature review (1970-2005), identify the elements of a CP history that might be most helpful to the clinician in identifying ACS.
CP characteristics that INCREASE likelihood of ACS/MI:
| Characteristic | # of Patients | LR |
|---|---|---|
| Radiating to both shoulders/arms | 893 | 4.1 |
| Radiating to right shoulder | 770 | 4.7 |
| Pain precipitated with exertion | 893 | 2.4 |
| Pain associated with diaphoresis | 8,426 | 2.0 |
CP characteristics that DECREASE likelihood of ACS/MI:
| Characteristic | # of Patients | LR |
|---|---|---|
| Pain that is sharp/stabbing | 1,088 | 0.3 |
| Pleuritic pain | 8,822 | 0.2 |
| Positional pain | 8,330 | 0.3 |
| Pain reproducible by palpation | 8,822 | 0.3 |
NOTE: Beware the chest pain which radiates to the RIGHT shoulder (LR = 4.7).
Clinical features have a limited role in triage decision-making for ACS/AMI
Study Design: Prospective, observation cohort study
Objective: Assess the performance of clinical features used in the diagnosis of CP, specifically in patients who were clinically stable and had a non-diagnostic ECG.
Results: (n=893)
- Predictive of ACS/AMI:
- Exertional pain
- Pain radiating to both arms > right arm
- NOT predictive of ACS/AMI:
- Presence of chest wall tenderness
- Nausea or vomiting
- Diaphoresis
History alone can help, but can NOT rule out ACS/AMI!
Objective: To identify clinical features that would increase or decrease the probability of an AMI, presenting with acute CP through a literature review (1980-1991).
Features that INCREASE the probability of an AMI
| Clinical Feature | LR |
|---|---|
| Chest pain that radiates to both arms | 7.1 |
| Chest pain that radiates to right shoulder | 2.9 |
Features that DECREASE the probability of an AMI
| Clinical Feature | LR |
|---|---|
| Pleuritic chest pain | 0.2 |
| Chest pain that is sharp or stabbing | 0.3 |
| Positional chest pain | 0.3 |
| Chest pain reproduced by palpation | 0.3 |
References
- M. Edwards, A.M. Chang, A.C. Matsuura, M. Green, J.M. Robey, and J.E. Hollander, "Relationship between pain severity and outcomes in patients presenting with potential acute coronary syndromes.", Annals of emergency medicine, 2011. [PubMed]
- R. Body, S. Carley, C. Wibberley, G. McDowell, J. Ferguson, and K. Mackway-Jones, "The value of symptoms and signs in the emergent diagnosis of acute coronary syndromes.", Resuscitation, 2009 [PubMed]
- C.J. Swap, and J.T. Nagurney, "Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes.", JAMA : the journal of the American Medical Association, 2005.(%20http://www.ncbi.nlm.nih.gov/pubmed/16304077)
- S. Goodacre, T. Locker, F. Morris, and S. Campbell, "How useful are clinical features in the diagnosis of acute, undifferentiated chest pain?", Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 2002. [PubMed]
- A.A. Panju, B.R. Hemmelgarn, G.H. Guyatt, and D.L. Simel, "The rational clinical examination. Is this patient having a myocardial infarction?", JAMA : the journal of the American Medical Association, 1998. [PubMed]
- S.R. Pitts, R.W. Niska, J. Xu, and C.W. Burt, "National Hospital Ambulatory Medical Care Survey: 2006 emergency department summary.", National health statistics reports, 2008. [PubMed]
- C.V. Pollack, F.D. Sites, F.S. Shofer, K.L. Sease, and J.E. Hollander, "Application of the TIMI risk score for unstable angina and non-ST elevation acute coronary syndrome to an unselected emergency department chest pain population.", Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 2005. [PubMed]
