Independent blinded reference standard, applied in all patients from a consecutive appropriate spectrum.
Reference standard: Diagnostic test: no enzyme abnormalities or recurrent chest pain during 12 hours of observation

The evidence

pre-test probability of myocardial infarction: 7.0%, (95% CI: 5.4% to 8.6%)

Chest pain: low risk patients: no enzymatic changes or pain after 12 hours, make an MI very unlikely.

Clinical bottom line (level 1a)

  1. 7% of patients ranked at low risk for a myocardial infarction have one.
  2. Low-risk patients who have no recurrent chest pain and no enzymatic changes after 12 hours are very unlikely to have a myocardial infarction (LR-0.069) .
Lee et al: New England Journal of Medicine 1991; 324 (18): 1239-1246
Goldman et al: New England Journal of Medicine 1988; 318: 797-803
Expires March 2003

The study

Setting: emergency departments, 7 acute hospitals, USA

957 patients (aged mean 62, 56% male) with anterior, precordial or left-sided chest pain who were classified at low-risk for myocardial infarction (< 7%) using Goldman clinical prediction rule

Excluded if
  • chest pain due to trauma or abnormalities on chest X-ray
  • aged < 30



    • Independent blinded reference standard, applied in all patients from a consecutive appropriate spectrum.
    Reference standard:
    • typical rise and fall in cardiac enzymes (CK-MB present; total CK at least twice the upper limit of normal; LDH-1 > LDH-2 in the absence of haemolysis or renal infarction) or a sudden cardiac arrest during hospital admission
    Diagnostic test: no enzyme abnormalities or recurrent chest pain during 12 hours of observation

    The evidence

    pre-test probability of myocardial infarction: 7.0%, (95% CI: 5.4% to 8.6%)

    diagnostic test myocardial infarction no MI LR+
    (95% CI)    		 post-test probability LR-
    (95% CI)    		 post-test probability
    cardiac enzyme rise or recurrent chest pain within 12 hours 63 123 6.8
    (5.7 to 8.1)     		34% 0.069
    (0.027 to 0.18)     		0.5%
    total 67 890

    Comments

    1. 8/771 patients died during hospitalisation (1.0%: 95% CI: 0.3% to 1.8%) - three had a cardiac arrest.
    2. 3/769 patients developed life-threatening complications (pericardial tamponade, and 2 cardiac arrests) (0.4%: 95% CI: 0.0% to 0.8%)
    3. 957/2684 patients were classified as low risk (36%: 95% CI: 34% to 38%)
    4. This is a prospective validation of a clinical prediction rule.

    Citation

    1. Lee TH, Juarez G, Cook EF, et al: Ruling out acute myocardial infarction: a prospective multicenter validation of a 12-hour strategy for patients at low risk. New England Journal of Medicine 1991; 324 (18): 1239-1246
    2. Goldman L, Cook EF, Brand DA, et al: A computer protocol to predict myocardial infarction in emergency department patients with chest pain. New England Journal of Medicine 1988; 318: 797-803
    Search Terms: reference from review article
    Contributor: Chris Ball and Clare Wotton, January 2001
    Reviewer:

    Clinical Question.
    Patient chest pain and low-risk
    Intervention or Exposure enzymatic changes
    Outcome MI
diagnostic test myocardial infarction no MI LR+
(95% CI)		 post-test probability LR-
(95% CI)		 post-test probability
cardiac enzyme rise or recurrent chest pain within 12 hours 63 123 6.8
(5.7 to 8.1) 		34% 0.069
(0.027 to 0.18) 		0.5%
total 67 890

Comments

  1. 8/771 patients died during hospitalisation (1.0%: 95% CI: 0.3% to 1.8%) - three had a cardiac arrest.
  2. 3/769 patients developed life-threatening complications (pericardial tamponade, and 2 cardiac arrests) (0.4%: 95% CI: 0.0% to 0.8%)
  3. 957/2684 patients were classified as low risk (36%: 95% CI: 34% to 38%)
  4. This is a prospective validation of a clinical prediction rule.

Citation

  1. Lee TH, Juarez G, Cook EF, et al: Ruling out acute myocardial infarction: a prospective multicenter validation of a 12-hour strategy for patients at low risk. New England Journal of Medicine 1991; 324 (18): 1239-1246
  2. Goldman L, Cook EF, Brand DA, et al: A computer protocol to predict myocardial infarction in emergency department patients with chest pain. New England Journal of Medicine 1988; 318: 797-803
Search Terms: reference from review article
Contributor: Chris Ball and Clare Wotton, January 2001
Reviewer:

Clinical Question.
Patient chest pain and low-risk
Intervention or Exposure enzymatic changes
Outcome MI