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Factors influencing physician risk estimates for acute cardiac events in emergency patients with suspected acute coronary syndrome
  1. Jaimi H Greenslade1,2,
  2. Nicolas Sieben3,
  3. William A Parsonage2,4,
  4. Thomas Knowlman5,
  5. Lorcan Ruane4,
  6. Martin Than6,
  7. John W Pickering6,7,
  8. Tracey Hawkins1,
  9. Louise Cullen1,3
  1. 1Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
  2. 2Institute of Health and Biomedical Innovation, School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
  3. 3Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
  4. 4Department of Cardiology, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
  5. 5Department of Medicine, Cairns Hospital, Cairns, Queensland, Australia
  6. 6Department of Emergency Medicine, Christchurch Hospital, Christchurch, New Zealand
  7. 7Department of Medicine, University of Otago, Christchurch, New Zealand
  1. Correspondence to A/Prof Jaimi H Greenslade, Emergency and Trauma Centre, Royal Brisbane and Women's Hospital, Herston, QLD 4029, Australia; jaimi.greenslade{at}


Background Emergency physicians frequently assess risk of acute cardiac events (ACEs) in patients with undifferentiated chest pain. Such estimates have been shown to have moderate to high sensitivity for ACE but are conservative. Little is known about the factors implicitly used by physicians to determine the pretest probability of risk. This study sought to identify the accuracy of physician risk estimates for ACE in patients presenting to the ED with chest pain and to identify the demographic and clinical information emergency physicians use in their determination of patient risk.

Methods This study used data from two prospective studies of consenting adult patients presenting to the ED with symptoms of possible acute coronary syndrome. ED physicians estimated the pretest probability of ACE. Multiple linear regression analysis was used to identify predictors of physician risk estimates. Logistic regression was used to determine whether there was a correlation between physicians’ estimated risk and ACE.

Results Increasing age, male sex, abnormal ECG features, heavy/crushing chest pain and risk factors were correlated with physician risk estimates. Physician risk estimates were consistently found to be higher than the expected proportion of ACE from the sampled population.

Conclusion Physicians systematically overestimate ACE risk. A range of factors are associated with physician risk estimates. These include factors strongly predictive of ACE, such as age and ECG characteristics. They also include other factors that have been shown to be unreliable predictors of ACE in an ED setting, such as typicality of pain and risk factors.

  • acute coronary syndrome
  • clinical assessment
  • cardiac care, diagnosis

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  • Contributors All authors met the requirements of authorship. JHG, NS, TK, LR, JWP, MT, WAP and LC conceived and designed the study. JHG, WAP, MT, TH and LC were involved in acquisition of data. JHG analysed the data. WAP, NS, TK, LR, JWP, MT and LC assisted with the interpretation of the data. JHG, NS and LC drafted the work, and all authors revised the manuscript critically for important intellectual content.

  • Funding Data collection was funded by research grants from the Emergency Medicine Foundation (QEMRF-PROJ-2008-002; QEMRF-PROG-2010-004).

  • Competing interests WAP and LC report funding from Beckmans and Abbott point of care in the form of a research grant paid to the institution. MT and JWP report funding from Abbott point of care and Roche in the form of a research grant paid to the institution. They also report consultancy from Abbott diagnostics.

  • Patient consent for publication Not required.

  • Ethics approval The study protocols were approved by the institutions’ human research and ethics committees and complied with the Declaration of Helsinki. The study was approved by the Royal Brisbane Women’s Hospital. The ethics/project approval numbers are HREC/2008/101 and HREC/10/QRBW/403.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement No data are available.