Chest pain: the type and position of pain was less helpful in the elderly at diagnosing MI.

Clinical bottom line (level 1b)

  1. Patients under 65 were more likely to have had an MI if:
    • emergency department ECG changes of ischaemia or infarction not known to be old (LR+5.9)
    • pain worse than prior angina or like prior MI (LR+2.2)
    • sweating (LR+2.1)
  2. Patients under 65 were less likely to have had an MI if:
    • pain reproduced by chest wall palpation (LR+0.19)
    • pain reproduced by deep breathing (LR+0.23)
    • pain reproduced by changes in position (LR+0.27)
    • no emergency department ECG changes of ischaemia or infarction, or changes known to be old (LR+0.30)
    • chest pain not mainly substernal (LR+0.39)
    • female (LR+0.53)
  3. Patients over 65 were more likely to have had an MI if:
    • emergency department ECG changes of ischaemia or infarction not known to be old (LR+3.2)
    • sweating (LR+1.8)
  4. Patients over 65 were less likely to have had an MI if:
    • pain reproduced by chest wall palpation (LR+0.31)
    • pain reproduced by deep breathing (LR+0.18)
    • pain reproduced by changes in position (LR+0.28)
    • no emergency department ECG changes of ischaemia or infarction, or known to be old (LR+0.39)
Solomon et al: American Journal of Cardiology 1989; 63: 772-776
Expires March 2003

The study

Setting: emergency departments of seven university hospitals, USA

7734 patients (aged 2625 aged > 65: median 73; . 5109 aged < 65; median 50, 52% female) chief complaint of anterior, precordial or left lateral chest pain

Excluded if
  • <30 years old
  • local chest trauma
  • abnormal chest x-ray
  • more than three visits to the emergency department



    • Independent blinded reference standard, applied in all patients from a consecutive appropriate spectrum.
    Reference standard:
    • MI if any of:
      • AST > twice upper limit of normal, which then returned to normal. No intramuscular injection, muscle trauma or hepatic disease
      • CK-MB > 5% total CK
      • LDH1 > LDH2. No haemolytic anaemia or renal infarction.
      • ECG - new pathological q waves (> 40 ms duration and > 25% decrease in amplitude of following R wave)
      • scintiscan showing focal uptake in cardiac area; if enzyme peak occurred before hospital admission and patient had no previous MI or valve calcification
      unstable angina if any of:
      • senior clinician's diagnosis not contraindicated by follow-up
      • abnormal exercise tolerance test, abnormal angiogram or follow-up history
      • known angina pain which worsened
    Diagnostic test:
    • history and physical
    • CK, AST, LDH

    • 89% of patients followed up.

    The evidence

    pre-test probability of MI in all patients: 14%, (95% CI: 14% to 15%)
    pre-test probability of MI in patients 65 or older: 20%, (95% CI: 19% to 22%)
    pre-test probability of MI in patients <65: 12%, (95% CI: 11% to 12%)
    pre-test probability of acute ischaemic heart disease (MI or unstable angina) in all patients: 30%, (95% CI: 29% to 31%)
    pre-test probability of acute IHD in patients 65 or older: 44%, (95% CI: 42% to 45%)
    pre-test probability of acute IHD in patients <65: 24%, (95% CI: 23% to 25%)

    diagnostic test MI in patients <65 no MI LR+
    (95% CI)    		 post-test probability LR-
    (95% CI)    		 post-test probability
    male 435 2309 1.5
    (1.4 to 1.5)     		16% 0.53
    (0.47 to 0.61)     		7%
    prior history of MI or angina 232 1314 1.4
    (1.2 to 1.5)     		15% 0.85
    (0.80 to 0.91)     		10%
    pressure sensation 398 1910 1.6
    (1.5 to 1.7)     		17% 0.56
    (0.50 to 0.63)     		7%
    mainly substernal pain location 510 2961 1.3
    (1.3 to 1.4)     		15% 0.39
    (0.32 to 0.48)     		5%
    radiation of pain to jaw, neck, left arm, left shoulder 307 1560 1.5
    (1.4 to 1.7)     		16% 0.73
    (0.67 to 0.80)     		9%
    pain worse than prior angina or like prior MI 174 619 2.2
    (1.9 to 2.5)     		22% 0.82
    (0.77 to 0.86)     		10%
    sweating 323 1195 2.1
    (1.9 to 2.3)     		21% 0.61
    (0.56 to 0.67)     		7%
    pain reproduced by chest wall palpation 22 899 0.19
    (0.12 to 0.28)     		2% 1.2
    (1.2 to 1.2)     		14%
    by deep breathing 29 956 0.23
    (0.16 to 0.33)     		3% 1.2
    (1.2 to 1.2)     		14%
    by changes in position 26 728 0.27
    (0.19 to 0.40)     		3% 1.1
    (1.1 to 1.2)     		13%
    emergency department ECG changes of ischaemia or infarction not known to be old 434 567 5.9
    (5.4 to 6.4)     		43% 0.30
    (0.26 to 0.34)     		4%
    total 589 4520


    diagnostic test MI in patients 65 or more no MI LR+
    (95% CI)    		 post-test probability LR-
    (95% CI)    		 post-test probability
    male 276 818 1.3
    (1.2 to 1.5)     		25% 0.79
    (0.71 to 0.86)     		17%
    prior history of MI or angina 294 1272 0.91
    (0.84 to 0.99)     		19% 1.1
    (1.0 to 1.3)     		22%
    pressure sensation 335 1056 1.3
    (1.2 to 1.4)     		24% 0.74
    (0.66 to 0.84)     		16%
    mainly substernal pain location 442 1502 1.2
    (1.1 to 1.2)     		23% 0.59
    (0.48 to 0.72)     		13%
    radiation of pain to jaw, neck, left arm, left shoulder 228 686 1.3
    (1.2 to 1.5)     		25% 0.85
    (0.78 to 0.92)     		18%
    pain worse than prior angina or like prior MI 201 606 1.3
    (1.2 to 1.5)     		25% 0.87
    (0.81 to 0.94)     		18%
    sweating 273 597 1.8
    (1.6 to 2.0)     		31% 0.68
    (0.62 to 0.74)     		15%
    pain reproduced by chest wall palpation 17 215 0.31
    (0.19 to 0.51)     		7% 1.1
    (1.1 to 1.1)     		21%
    by deep breathing 11 241 0.18
    (0.10 to 0.33)     		4% 1.1
    (1.1 to 1.1)     		22%
    by changes in position 11 154 0.28
    (0.15 to 0.52)     		7% 1.1
    (1.0 to 1.1)     		21%
    emergency department ECG changes of ischaemia or infarction not known to be old 368 453 3.2
    (2.9 to 3.6)     		45% 0.39
    (0.34 to 0.44)     		9%
    total 530 2095

    Comments

    1. Features that became significantly less helpful in the elderly compared with young patients were:
      • male sex
      • pain location and similarity to prior MI/ angina
      • ECG changes in the emergency department

    Citation

    1. Solomon CG, Lee TH, Cook EF, et al: Comparison of clinical presentation of acute myocardial infarction in patients older than 65 years of age to younger patients: the multicenter chest pain study experience. American Journal of Cardiology 1989; 63: 772-776
    Contributor: Chris Ball and Clare Wotton, March 2000
    Reviewer:

    Clinical Question.
    Patient elderly patients with chest pain
    Intervention or Exposure type and position of pain
    Outcome diagnosis of MI