Value and Limitations of Chest Pain History in the Evaluation of Patients With Suspected Acute Coronary Syndromes

Abstract

Context The chest pain history, physical examination, determination of coronary artery disease (CAD) risk factors, and the initial electrocardiogram compose the information immediately available to clinicians to help determine the probability of acute myocardial infarction (AMI) or acute coronary syndrome (ACS) in patients with chest pain. However, conflicting data exist about the usefulness of the chest pain history and which components are most useful. Objective To identify the elements of the chest pain history that may be most helpful to the clinician in identifying ACS in patients presenting with chest pain. Evidence Acquisition MEDLINE and Ovid were searched from 1970 to September 2005 by using specific key words and Medical Subject Heading terms. Reference lists of these articles and current cardiology textbooks were also consulted. Evidence Synthesis Certain chest pain characteristics decrease the likelihood of ACS or AMI, namely, pain that is stabbing, pleuritic, positional, or reproducible by palpation (likelihood ratios [LRs] 0.2-0.3). Conversely, chest pain that radiates to one shoulder or both shoulders or arms or is precipitated by exertion is associated with LRs (2.3-4.7) that increase the likelihood of ACS. The chest pain history itself has not proven to be a powerful enough predictive tool to obviate the need for at least some diagnostic testing. Combinations of elements of the chest pain history with other initially available information, such as a history of CAD, have identified certain groups that may be safe for discharge without further evaluation, but further study is needed before such a recommendation can be considered reasonable. Conclusion Although certain elements of the chest pain history are associated with increased or decreased likelihoods of a diagnosis of ACS or AMI, none of them alone or in combination identify a group of patients that can be safely discharged without further diagnostic testing.

Presentation of Coronary Artery Disease in a Chiropractic Clinic: A Report of 2 Cases

“…16,17 There are additional clinical factors in cardiovascular disorders, such as sex differences, that can also affect the clinical presentation. For example, women may present with a different intensity of chest pain symptoms, fatigue, and/or shortness of breath than would be typically expected of men.…”

“…1,18 Other symptoms that may be associated with chest pain include diaphoresis, dyspnea, nausea/ vomiting, dizziness, syncope or collapse, palpitation, weakness, fear, and anxiety. 16 Physical signs that are indicative of cardiovascular disease and that are measurable in a clinical setting include elevated blood pressure, tachycardia, bradycardia, and rales. 1,4 Validated clinical prediction rules can be particularly helpful for clinicians in determining the presence or absence of disease.…”

“…It is important to differentiate specific acute coronary syndromes from severe or benign causes of chest pain as the consequences of a misdiagnosis can be drastic. 16 On the other hand, inadequate assessment and management of patients with suspected acute coronary syndrome can lead to inappropriate and harmful investigations as well as higher costs. Alternatively, patients with a cardiovascular event that are misdiagnosed may continue to be untreated.…”

“…11 Serious pathologies including coronary artery disease can have similar symptom presentation to musculoskeletal chest pain, making a clear diagnosis challenging. 16 Several studies have found chest pain of musculoskeletal etiology to be the most frequent presentation in chest pain clinics. 4,16,[20][21][22] Diagnostically, musculoskeletal chest pain can be reproduced with arm or neck movement.…”

“…16 Several studies have found chest pain of musculoskeletal etiology to be the most frequent presentation in chest pain clinics. 4,16,[20][21][22] Diagnostically, musculoskeletal chest pain can be reproduced with arm or neck movement. 23 However, as with case 1 in this study, the patient's symptoms could be reproduced with thoracic spine movements, which is a sign inconsistent of cardiovascular origin.…”