Chest pain: clinical features and ECG helped diagnose myocardial infarction.

Clinical bottom line (level 2a)

  1. Patients with chest pain that radiated down their arms, caused nausea and vomiting or sweating were more likely to have an MI. A third heart sound, pulmonary crackles or hypotension also made an MI more likely.
  2. Patients with chest pain that was positional, sharp, pleuritic or reproduced by palpation were less likely to have an MI.
  3. ST elevation, conduction defects and Q waves on ECG helped predict an MI. A normal ECG made it less likely.
Panju et al: Journal of the American Medical Association 1998; 280 (14): 1256-1263
Expires July 2003

The study

Systematic review of ?all of
  • Patients: presenting with chest pain
  • Intervention: clinical examination for airflow limitation compared with reference standard (usually FEV1 and FVC by spirometry)
  • Outcome: diagnosis of MI


Articles found in English using MEDLINE, 1980 to 1997 (search terms: medical history taking or physical examination and myocardial infarction or chest pain; also reproducibility of results or observer variation and myocardial infarction or chest pain ) and bibliographies and textbooks were also searched

Selection criteria: as above
Appraisal criteria: appraised using set criteria (detailed in text) and graded according to quality
Articles excluded if: sample size <200

Fourteen studies were found: five involving patients presenting to the emergency department with chest pain, seven involving patients admitted to hospital or CCU for suspected MI and two involving patients with chest pain brought to the emergency department by paramedics
  • Reference standard based on cardiac enzyme and ECG changes.

The evidence


diagnostic test MI no MI LR
(95% CI)		 post-test probability
pain in chest or left arm 2.7
( to ) 		%
chest pain radiation- right shoulder 2.9
(1.4 to 6.0) 		%
radiation- left arm 2.3
(1.7 to 3.1) 		%
radiation- both left and right arm 7.1
(3.6 to 14.2) 		%
chest pain most important symptom 2.0
( to ) 		%
history of MI
(1.5 to 3.0) 		%
nausea or vomiting 1.9
(1.7 to 2.3) 		%
sweating 2.0
(1.9 to 2.2) 		%
third heart sound on auscultation 3.2
(1.6 to 6.5) 		%
hypotension (systolic bp <80 mmHg) 3.1
(1.8 to 5.2) 		%
pulmonary crackles on ausculation 2.1
(1.4 to 3.1) 		%
pleuritic chest pain 0.2
(0.2 to 0.3) 		%
chest pain sharp or stabbing 0.3
(0.2 to 0.5) 		%
positional chest pain 0.3
(0.2 to 0.4) 		%
chest pain reproduced by palpation
(0.2 to 0.4) 		%
new ST-segmant elevation 1 mm or more
(5.7 to 54) 		%
any ST-segment elevation 11.2
(7.1 to 18) 		%
new conduction defect 6.3
(2.5 to 16) 		%
new ST depression
(3.0 to 5.2) 		%
any Q wave 3.9
(2.7 to 5.7) 		%
any ST-segment depression 3.2
(2.5 to 4.1) 		%
T-wave peaking and/or inversion 1 mm or more 3.1
( to ) 		%
new T-wave inversion
(2.4 to 2.8) 		%
any conduction defect 2.7
(1.4 to 5.4) 		%
normal ECG
(0.1 to 0.3) 		%
total

  • Where no confidence intervals given, there was not enough data to calculate them.
  • Where only "confidence intervals" are given, there was heterogeneity noted between the studies, and a range is supplied.
  • Clinicians agree reasonably well on clinical features in patients with chest pain: K interobserver 0.27 to 0.89.

Comments

  1. Only LR >2.0 or <0.5 were reported.
  2. The heterogeneity between studies is shown in the myocardial infarction pretest probabilities that vary from 12.4 to 85.1, and the number of patients in each study group (range 200-7734).
  3. Studies failed to show classic cardiac risk factors (smoking, hypertension, diabetes etc) as being predictive of MI.
  4. Few studies reported the accuracy of using combinations of these clinical features or ECG.
  5. A number of these studies selected have been appraised in the CATbank, and some used an inappropriate spectrum of patients. Consequently this systematic review can only be graded as 2a.

Citation

  1. Panju AA, Hemmelgarn BR, Guyatt GH, et al: Is this patient having a myocardial infarction?. Journal of the American Medical Association 1998; 280 (14): 1256-1263
Search Terms: hand search
Contributor: Chris Ball and Clare Wotton, July 2000
Reviewer: William Rhoton

Clinical Question.
    Patient chest pain
    Intervention or Exposure physical symptoms
    Outcome diagnosis of MI