Myocardial infarction: pleuritic chest pain ruled out myocardial infarction.

Clinical bottom line (level 1b)

  1. Patients with chest pain which is pleuritic did not have a myocardial infarction or unstable angina (LR+0.00) , and those who did not were slightly more likely to (LR-1.12) .
  2. Patients who described their pain as 'pressure' were slightly more likely to have an MI or unstable angina (LR+1.67) , and those who did not were slightly less likely to (LR-0.67) .
  3. Patients with positional pain were less likely to have had an MI or unstable angina (LR+0.13) , and those who did not have positional pain were slightly more likely to (LR-1.06) .
Lee et al: Archives of Internal Medicine 1985; 145: 65-69
Expires March 2003

The study

Setting: general hospital, USA

596 patients (aged mean 56 years, 52% female) anterior, precordial or left-sided chest pain unexplained by obvious trauma or abnormalities on chest roentgenograms

Excluded if
  • <25 years old

Independent blinded reference standard, applied in all patients from a consecutive appropriate spectrum.
Reference standard:

  • ECG and cardiac enzyme measurement- SGOT, lactate dehydrogenase and creatine kinase (measured when they started to rise). Diagnosis of myocardial infarction was made if abnormalities were detected in any of the following: 1. serum enzyme levels above normal and at least twice the admission value, which then returned to normal in a patient who did not have i.m. injections, muscle trauma or hepatobiliary disease; CK-MB isoenzyme detected in more than trace amounts by the qualitative assay used in the early months of the study or in amounts at least 5% of the total CK level by the quantitative assay used thereafter; or LDH isoenzyme greater than defined level in the absence of haemolytic anaemia or renal infarction; 2. ECGs showing development of new pathologic Q waves (at least 0.04 s in duration) and at least a 25% decrease in the amplitude of the following R wave as compared with that of the emergency room m ECG; 3. Scintiscan showing focal uptake in the cardiac area if serum enzyme peak might have occurred before hospitalisation and if patients had no earlier history of MI or valvular calcification. Unstable angina was diagnosed if MI was not confirmed and if it was diagnosed by a senior clinician with no later contradiction, and if the pain was worse than any previous anginal pain.
Diagnostic test: clinical and physical findings- age, sex, quality of chest pain, presence or absence of radiation, diaphoresis, risk factors, response of pain to antacids or sublingual nitroglycerin, presence of pleuritic or positional components to the pain, ability of chest wall pressure to reproduce the pain

The evidence

pre-test probability of myocardial infarction: 17.4%, (95% CI: 14.4% to 20.5%)
pre-test probability of myocardial infarction or unstable angina: 41.4%, (95% CI: 37.5% to 45.4%)

diagnostic test myocardial infarction or unstable angina no myocardial infarction or unstable angina LR+
(95% CI)		 post-test probability LR-
(95% CI)		 post-test probability
aged 80 or over 35 212 3.50
(1.94 to 6.42) 		71.0% 0.89
(0.85 to 0.94) 		39.0%
aged 70-79 43 204 2.17
(1.39 to 3.39) 		61.0% 0.90
(0.84 to 0.96) 		39.0%
aged 60-69 75 172 1.77
(1.31 to 2.38) 		56.0% 0.84
(0.76 to 0.92) 		37.0%
aged 50-59 56 191 1.13
(0.83 to 1.54) 		44.0% 0.97
(0.89 to 1.05) 		41.0%
aged 40-49 31 216 0.50
(0.34 to 0.72) 		26.0% 1.17
(1.08 to 1.26) 		45.0%
aged 30-39 5 242 0.12
(0.05 to 0.28) 		8.00% 1.19
(1.13 to 1.25) 		46.0%
aged 25-29 years 2 245 0.10
(0.02 to 0.42) 		7.00% 1.08
(1.04 to 1.11) 		43.0%
pleuritic pain 0 247 0.00
(0.00 to 1.22) 		0.00% 1.12
(1.08 to 1.16) 		44.0%
pain described as 'pressure' 137 110 1.67
(1.39 to 2.01) 		54.0% 0.67
(0.57 to 0.78) 		32.0%
sharp or stabbing pain 35 212 0.41
(0.29 to 0.57) 		22.0% 1.32
(1.20 to 1.45) 		48.0%
male sex 135 112 1.26
(1.07 to 1.49) 		47.0% 0.80
(0.68 to 0.94) 		36.0%
positional pain 2 245 0.13
(0.030 to 0.54) 		8.00% 1.06
(1.03 to 1.09) 		43.0%
total 104 492

  • Aching or burning pain is not helpful at diagnosing or excluding myocardial infarction or unstable angina.

Citation

  1. Lee TH, Cook F, Weisberg M, et al: Acute chest pain in the emergency room: Identification and examination of low-risk patients. Archives of Internal Medicine 1985; 145: 65-69
Contributor: Clare Wotton and Musab Hayatli, March 2000
Reviewer: Dwight Peretz

Clinical Question.
Patient chest pain
Intervention or Exposure physical findings
Comparison ECG
Outcome diagnosis