Independent blinded reference standard, applied in all patients from a non-consecutive appropriate spectrum.
Reference standard: Diagnostic test: rapid chest pain evaluation: positive if:

The evidence

pre-test probability of : 9.5%, (95% CI: 6.2% to 13%)

Chest pain: rapid evaluation schemes could exclude acute cardiac ischaemia.

Clinical bottom line (level 2b)

  1. In patients with chest pain considered to be a low-risk for acute cardiac ischaemia, a rapid evaluation protocol could rule it out (post-test probability 2%).
Zalenski et al: Archives of Internal Medicine 1997; 157: 1085-1091
Expires March 2003

The study

Setting: municipal hospital, USA

317 patients (aged range 20 to 82 years; mean 47, 54% male) with chest pain considered low-risk for ischaemic heart disease (based on a clinical prediction rule by Goldman et al)

Excluded if
  • confirmed diagnosis (from cardiac testing, q waves on ECG or probable/ definite history of angina)
  • cardiac complications before enrolment
  • safety risks (AF, frequent PVCs)
  • inability to exercise (incapacitating dyspnoea or walking 2 blocks or climbing 1 flight of stairs)
  • concurrent non-cardiac problem requiring admission



    • Independent blinded reference standard, applied in all patients from a non-consecutive appropriate spectrum.
    Reference standard:
    • admission for 48 hours:
      • 4 sets of CK-MB
      • 3 ECGs
      • 24 hours cardiac monitoring and clinical evaluation
      MI if any of:
      • ECG with q waves 40 ms wide and 1/4 height of R wave in 2 contiguous leads
      • CK > 130 and CK-MB/CK 2.5 or more within 72 hours
      • LDH1: LDH2 0.75 or more
      • sudden death < 24 hours without other cause
      acute cardiac ischaemia if any of:
      • positive angiography: 50% or more stenosis of left main coronary artery or 60% or more stenosis any other vessel
      • positive thallium scinitillography or stress echocardiogram
      • new ST elevation/ depression on ECG taken at rest
      • cardiogenic shock
      • pump failure (as compared with baseline CXR)
      • VT, VF, heart block, cardiac arrest
      • senior clinician opinion
      Positive exercise test alone insufficient.
    Diagnostic test: rapid chest pain evaluation:
    • CK-MB at 0, 4, 8, 12 hours
    • serial 12-lead ECGs
    • clinical assessment at 0, 6, 12 hours
    • exercise ECG: if all the above negative within 2 hours
    positive if:
    • CK-MB 4.7 or more ng/ml
    • ECG - ST elevation/ depression 0.1 mV or more or T wave inversions, or ECG with q waves 40 ms wide and 1/4 height of R wave in 2 contiguous leads
    • clinical assessment that patient at high-risk (any 4 of substernal location; heavy/ constricting quality; radiation to left arm; exertion-rest pattern or relief with GTN; pain with dyspnoea or sweating)
    • exercise test: 0.1 mV horizontal or down-sloping depression 80 ms beyond J-point

    The evidence

    pre-test probability of : 9.5%, (95% CI: 6.2% to 13%)

    diagnostic test acute cardiac ischaemia no acute cardiac ischaemia LR+
    (95% CI)    		 post-test probability LR-
    (95% CI)    		 post-test probability
    protocol positive 27 142 1.8
    (1.5 to 2.2)     		16% 0.20
    (0.067 to 0.58)     		2%
    total 30 287


    diagnostic test acute cardiac ischaemia no acute cardiac ischaemia LR
    (95% CI)    		 post-test probability
    exercise ECG 4 13 5.4
    (2.1 to 14)     		24%
    inconclusive 5 54 1.6
    (0.81 to 3.3)     		8%
    negative 3 145 0.37
    (0.14 to 0.98)     		2%
    total 11 212

    • CK-MB
      • sens 39.3%; spec 90.4%
      • LR+ 4.1; LR- 0.67
      +ECG
      • sens 53.3%; spec 83.6%
      • LR+ 3.3; LR- 0.56
      +clinical exam
      • sens 60.0%; spec 73.3%
      • LR+ 2.2; LR- 0.55
      +exercise ECG
      • sens 90.0%; spec 50.5%
      • LR+ 1.8; LR- 0.20

    Comments

    1. How much do these results reflect the group studied? Mainly men and mainly ex-US soldiers.

    Citation

    1. Zalenski RJ, McCarren M, Roberts R, et al: An evaluation of a chest pain diagnostic protocol to exclude acute cardiac ischemia in the emergency department.. Archives of Internal Medicine 1997; 157: 1085-1091
    Search Terms: chest pain in Cochrane
    Contributor: Chris Ball and Clare Wotton, Unknown Month 2000
    Reviewer:

    Clinical Question.
    Patient chest pain
    Intervention or Exposure rapid evaluation protocol
    Outcome diagnosis of acute cardiac ischaemia
diagnostic test acute cardiac ischaemia no acute cardiac ischaemia LR+
(95% CI)		 post-test probability LR-
(95% CI)		 post-test probability
protocol positive 27 142 1.8
(1.5 to 2.2) 		16% 0.20
(0.067 to 0.58) 		2%
total 30 287


diagnostic test acute cardiac ischaemia no acute cardiac ischaemia LR
(95% CI)		 post-test probability
exercise ECG 4 13 5.4
(2.1 to 14) 		24%
inconclusive 5 54 1.6
(0.81 to 3.3) 		8%
negative 3 145 0.37
(0.14 to 0.98) 		2%
total 11 212

Comments

  1. How much do these results reflect the group studied? Mainly men and mainly ex-US soldiers.

Citation

  1. Zalenski RJ, McCarren M, Roberts R, et al: An evaluation of a chest pain diagnostic protocol to exclude acute cardiac ischemia in the emergency department.. Archives of Internal Medicine 1997; 157: 1085-1091
Search Terms: chest pain in Cochrane
Contributor: Chris Ball and Clare Wotton, March 2000
Reviewer:

Clinical Question.
Patient chest pain
Intervention or Exposure rapid evaluation protocol
Outcome diagnosis of acute cardiac ischaemia