Chest pain: myocardial infarction was the commonest cause.

Clinical bottom line (level 4)

  1. In patients presenting with chest pain, around a third had an MI, and a further sixth unstable angina.
  2. One in twenty were diagnosed with a pulmonary embolus.
Berger et al: Annals of Internal Medicine 1990; 227: 165-172
Expires March 2003

The study

Setting: emergency admissions ward of Swiss hospital

278 patients (aged mean 57.3yr, 69% male) chest pain

Excluded if
  • trauma
  • inter-hospital transfers



Non-independent unblinded reference standard, applied in all patients from a consecutive appropriate spectrum.
Reference standard:
  • Varied with condition
    • MI : chest pain, ECG changes, significant CK elevation
    • Unstable angina : worsening angina, suspected MI which did not fulfil criteria
    • Stable angina : "highly likely" in the opinion of the admitting team
    • Other disorders : no formal diagnostic standards given

The evidence


differential diagnosis number of patients prevalence
(95% CI)
myocardial infarction 100 36.0%
(30.3% to 41.6%)
unstable angina 47 16.9%
(12.5% to 21.3%)
stable angina 25 9.0%
(5.6% to 12.4%)
pulmonary embolus 16 5.8%
(3.0% to 8.5%)
other pulmonary pathology 16 5.8%
(3.0% to 8.5%)
chest wall pain 15 5.4%
(2.7% to 8.1%)
pericarditis 14 5.0%
(2.5% to 7.6%)

Comments

  1. The lack of formal diagnostic criteria for non-cardiac conditions and the unblinded, non independent nature of the study make the findings less certain than the confidence intervals suggest.

Citation

  1. Berger JP, Buclin T, Haller E, et al: Right arm involvement and pain extension can help differentiate coronary diseases from chest pain of other origin: a prospective emergency ward study of 278 consecutive patients admitted for chest pain. Annals of Internal Medicine 1990; 227: 165-172
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Contributor: Bob Phillips and Clare Wotton, October 2000
Reviewer: Arnold Baas

Clinical Question.
    Patient chest pain
    Intervention or Exposure clinical findings
    Outcome differential diagnosis