Systematic review and modelling of the investigation of acute and chronic chest pain presenting in primary care

Mant, Jonathan; McManus, RJ; Oakes, Rachel; Delaney, Brendan; Barton, Pamela M.; Deeks, Jonathan J; Hammersley, Louise; Davies, Russell; Davies, M. K.; Hobbs, F D Richard

doi:10.3310/hta8020

Cited by 58 publications

(61 citation statements)

References 60 publications

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“…Previous reviews could not define an important role for signs and symptoms in general in the diagnosis of coronary artery disease and acute coronary syndromes. [8][9][10] Among the individual variables that were evaluated, age and history of prior myocardial infarction were effective for diagnosing typical angina (coronary artery disease), 9 and the absence of chestwall tenderness on palpation was effective for diagnosing acute coronary syndromes. 8,10 The variable "patient assumes pain is of cardiac origin" was not used in other studies and therefore remains a unique variable in our study population.…”

Section: Discussionmentioning

confidence: 99%

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Ruling out coronary artery disease in primary care: development and validation of a simple prediction rule

Bösner¹,

Haasenritter²,

Becker³

et al. 2010

Canadian Medical Association Journal

111

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Background: Chest pain can be caused by various conditions, with life-threatening cardiac disease being of greatest concern. Prediction scores to rule out coronary artery disease have been developed for use in emergency settings. We developed and validated a simple prediction rule for use in primary care. Methods:We conducted a cross-sectional diagnostic study in 74 primary care practices in Germany. Primary care physicians recruited all consecutive patients who presented with chest pain (n = 1249) and recorded symptoms and findings for each patient (derivation cohort). An independent expert panel reviewed follow-up data obtained at six weeks and six months on symptoms, investigations, hospital admissions and medications to determine the presence or absence of coronary artery disease. Adjusted odds ratios of relevant variables were used to develop a prediction rule. We calculated measures of diagnostic accuracy for different cut-off values for the prediction scores using data derived from another prospective primary care study (validation cohort). Results:The prediction rule contained five determinants (age/sex, known vascular disease, patient assumes pain is of cardiac origin, pain is worse during exercise, and pain is not reproducible by palpation), with the score ranging from 0 to 5 points. The area under the curve (receiver operating characteristic curve) was 0.87 (95% confidence interval [CI] 0.83-0.91) for the derivation cohort and 0.90 (95% CI 0.87-0.93) for the validation cohort. The best overall discrimination was with a cut-off value of 3 (positive result 3-5 points; negative result ≤ 2 points), which had a sensitivity of 87.1% (95% CI 79.9%-94.2%) and a specificity of 80.8% (77.6%-83.9%). Interpretation:The prediction rule for coronary artery disease in primary care proved to be robust in the validation cohort. It can help to rule out coronary artery disease in patients presenting with chest pain in primary care. AbstractPreviously published at www.cmaj.ca @@

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Section: Discussionmentioning

confidence: 99%

“…[8][9][10] Predictive scores have also been developed for use in emergency departments, mainly for the diagnosis of acute coronary syndromes. [11][12][13] To what degree these apply in primary care is unknown.…”

mentioning

confidence: 99%

Ruling out coronary artery disease in primary care: development and validation of a simple prediction rule

Bösner¹,

Haasenritter²,

Becker³

et al. 2010

Canadian Medical Association Journal

111

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“…The acceptance of a broad range of inclusion criteria (autopsy, sudden death, scintigraphy, echocardiography, and angiography) as reference tests increased the number of real positives at the risk of spectrum bias. 10 Verification bias was not a major problem because almost all patients received a reference standard. The increasing sensitivity of the blood tests used over the years -starting with transaminase via lactate dehydrogenase, creatine kinase (CK) and the isoenzyme CK-MB, and recently troponin T -has caused a rise in real positives.…”

Section: Qualitymentioning

confidence: 99%

“…In Mant's et al's study the absence of pleuretic pain had a LR-of 0.19 and the absence of positional pain a LR-of 0.27. 10 Oppressive pain, with a pooled sensitivity of 60% and a specificity of 58% has almost no influence on the likelihood of acute myocardial infarction. The sensitivities of the other signs and symptoms were even lower and could not be used to exclude acute myocardial infarction or acute coronary syndrome.…”

Section: Diagnostic Accuracy Of Signs and Symptoms In The Non-selectementioning

confidence: 99%

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Signs and symptoms in diagnosing acute myocardial infarction and acute coronary syndrome: a diagnostic meta-analysis

Bruyninckx¹,

Aertgeerts²,

Bruyninckx³

et al. 2008

Br J Gen Pract

120

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Diagnostic meta-analysis. MethodUsing MEDLINE, CINAHL, EMBASE, tracing references, and by contacting experts, studies were sought out that described one of the 10 signs and symptoms on one or both conditions. Studies were excluded if they were not based on original data. Validity was assessed using QUADAS and all data were pooled using a random effects model. ResultsSixteen of the 28 included studies were about patients who were non-selected. In this group, absence of chest-wall tenderness on palpation had a pooled sensitivity of 92% (95% confidence interval [CI] = 86 to 96) for acute myocardial infarction and 94% (95% CI = 91 to 96) for acute coronary syndrome. Oppressive pain followed with a pooled sensitivity of 60% (95% CI = 55 to 66) for acute myocardial infarction. Sweating had the highest pooled positive likelihood ratio (LR+), ConclusionsBased on this meta-analysis it was not possible to define an important role for signs and symptoms in the diagnosis of acute myocardial infarction or acute coronary syndrome. Only chest-wall tenderness on palpation largely ruled out acute myocardial infarction or acute coronary syndrome in low-prevalence settings.

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Coronary Heart Disease, Healthcare Policy and Evolution of Chest Pain Assessment and Management in the UK

Quinn¹

2007

Chest Pain

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Systematic review and modelling of the investigation of acute and chronic chest pain presenting in primary care

Cited by 58 publications

References 60 publications

Ruling out coronary artery disease in primary care: development and validation of a simple prediction rule

Ruling out coronary artery disease in primary care: development and validation of a simple prediction rule

Signs and symptoms in diagnosing acute myocardial infarction and acute coronary syndrome: a diagnostic meta-analysis

Coronary Heart Disease, Healthcare Policy and Evolution of Chest Pain Assessment and Management in the UK

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