Clinical research study
‘Chest Pain Typicality’ in Suspected Acute Coronary Syndromes and the Impact of Clinical Experience

https://doi.org/10.1016/j.amjmed.2015.04.012Get rights and content
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Abstract

Background

Physicians rely upon chest pain history to make management decisions in patients with suspected acute coronary syndromes, particularly where the diagnosis is not immediately apparent through electrocardiography and troponin testing. The objective of this study was to establish the discriminatory value of “typicality of chest pain” and the effect of clinician experience, for the prediction of acute myocardial infarction and presence of significant coronary artery disease.

Methods

This prospective single-center observational study was undertaken in a UK General Hospital emergency department. We recruited consecutive adults with chest pain and a nondiagnostic electrocardiogram, for whom the treating physician determined that delayed troponin testing was necessary. Using their own clinical judgment, physicians recorded whether the chest pain described was typical or atypical for acute coronary syndrome. Physicians were defined as “experienced” or “novice” according to postgraduate experience. Acute myocardial infarction was adjudicated using a high-sensitivity troponin (hs-cTn) assay, whereas coronary artery disease was adjudicated angiographically.

Results

Overall, 912 patients had typicality of chest pain assessed, of whom 114/912 (12.5%) had an acute myocardial infarction and 157/912 (17.2%) underwent angiography. In patients undergoing angiography, 90/157 (57.3%) had hs-cTn elevation, of whom 60 (66.7%) had significant coronary artery disease. Sixty-seven of 157 (42.7%) patients had angiography without hs-cTn elevation; of these, 31 (46.2%) had significant coronary artery disease. For the diagnosis of acute myocardial infarction, chest pain typicality had an area under the curve (AUC) of 0.54 (95% confidence interval [CI], 0.49-0.60). For the prediction of significant coronary artery disease with hs-cTn elevation AUC: 0.54 (95% CI, 0.40-0.67), and without hs-cTn elevation AUC: 0.45 (95% CI, 0.31-0.59). When assessed by experienced physicians, specificity for the diagnosis of acute myocardial infarction was higher at 65.8% (95% CI, 63.1%-68.7%) vs 55.4% (95% CI, 53.9%–56.8%) for novices.

Conclusions

Subjective interpretation of “typicality of chest pain” is of limited discriminatory value in the assessment of suspected acute coronary syndromes, in the context of a nondiagnostic electrocardiogram. Greater clinical experience improves accuracy as a rule-in tool but does not improve overall discriminatory ability.

Keywords

Acute coronary syndrome
Chest pain
Clinical experience
Coronary artery disease
Emergency department
High-sensitivity troponin
Myocardial infarction

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Funding: This study was supported by a research grant from the College of Emergency Medicine of the United Kingdom and research fellowship funding from Bournemouth University, UK.

Conflict of Interest: EC has received funding from Abbott in support for related research. MT has received funding from Alere, Abbott, Beckman, and Roche for speaking and support for other research. LC has received funding from Abbott, Roche, Alere, Siemens, and Radiometer Pacific for clinical trials, and from Alere, Boehringer Ingelheim, Pfizer, Astra Zeneca, Abbott, Novartis, and Radiometer Pacific for speaking and education. AK has no conflicts of interest. KG has received funding from AstraZeneca and Takeda UK for related research.

Authorship: Each author has contributed to the analysis and interpretation of the data, drafting and approval of the final manuscript. All authors have also contributed to the conception/design of the study reported in this manuscript.