Elsevier

Resuscitation

Volume 81, Issue 3, March 2010, Pages 281-286
Resuscitation

Clinical paper
The value of symptoms and signs in the emergent diagnosis of acute coronary syndromes

https://doi.org/10.1016/j.resuscitation.2009.11.014Get rights and content

Abstract

Objective

Patient history and physical examination are widely accepted as cornerstones of diagnosis in modern medicine. We aimed to assess the value of individual historical and examination findings for diagnosing acute myocardial infarction (AMI) and predicting adverse cardiac events in undifferentiated Emergency Department (ED) patients with chest pain.

Methods

We prospectively recruited patients presenting to the ED with suspected cardiac chest pain. Clinical features were recorded using a custom-designed report form. All patients were followed up for the diagnosis of AMI and the occurrence of adverse events (death, AMI or urgent revascularization) within 6 months.

Results

AMI was diagnosed in 148 (18.6%) of the 796 patients recruited. Following adjustment for age, sex and ECG changes, the following characteristics made AMI more likely (adjusted odds ratio, 95% confidence intervals): pain radiating to the right arm (2.23, 1.24–4.00), both arms (2.69, 1.36–5.36), vomiting (3.50, 1.81–6.77), central chest pain (3.29, 1.94–5.61) and sweating observed (5.18, 3.02–8.86). Pain in the left anterior chest made AMI significantly less likely (0.25, 0.14–0.46). The presence of rest pain (0.67, 0.41–1.10) or pain radiating to the left arm (1.36, 0.89–2.09) did not significantly alter the probability of AMI.

Conclusions

Our results challenge many widely held assertions about the value of individual symptoms and signs in ED patients with suspected acute coronary syndromes. Several ‘atypical’ symptoms actually render AMI more likely, whereas many ‘typical’ symptoms that are often considered to identify high-risk populations have no diagnostic value.

Section snippets

Background

The patient history and physical examination are widely accepted as the cornerstones of diagnosis in modern medicine. The European Society of Cardiology (ESC) and American Heart Association (AHA) both recommend that the history and examination should be utilised in patients presenting to the Emergency Department (ED) with suspected acute coronary syndromes (ACS) in order to assess the likelihood of ACS and to evaluate prognosis.1, 2 For example, the AHA guidelines state that “chest or left arm

Methods

We prospectively recruited patients in the ED at Manchester Royal Infirmary, a university-affiliated teaching hospital with an annual ED census of approximately 145,000 (comprising approximately 39,000 major cases, 43,000 minor injuries, 19,000 ophthalmological emergencies, 24,000 primary care emergencies, 13,000 presentations to the Walk in Centre and 7000 others). The study was approved by the Local Research Ethics Committee.

All patients aged >25 years who presented to the ED with suspected

Overview of data collection

804 patients were recruited to the study between January 2006 and February 2007. 8 patients were excluded because they were found to meet pre-defined exclusion criteria, meaning that 796 patients were entered into the final analysis. No patients were lost to follow-up within 6 months.

148 (18.6%) patients were diagnosed with AMI on their index admission. Of those patients, 13 (8.8%) died and 101 (68.2%) needed urgent revascularization within 6 months. Of the 648 patients who did not have index

Discussion

Our results demonstrate that while a number of clinical features can be used to shift the prior probability, none can be used alone to reliably confirm or exclude AMI or the occurrence of adverse events. Some ‘atypical’ symptoms (notably pain radiating to the right arm or shoulder) were shown to render AMI and the occurrence of adverse events significantly more likely. Others (for example, pleuritic pain, burning or indigestion-like pain and right sided chest pain) had no diagnostic or

Conclusions

Our findings challenge many widely held assertions about the value of individual symptoms and signs in ED patients with suspected ACS. Symptoms that are known to be ‘typical’ or ‘atypical’ of ACS may actually have little ability to differentiate the ED population with chest pain. Notably, several ‘atypical’ symptoms actually render the diagnosis of ACS more likely, whereas many ‘typical’ symptoms that are often considered to identify high-risk populations have no diagnostic value.

Conflict of interests

None declared.

Role of funding source

Central Manchester and Manchester Children's University NHS Trust sponsored and funded the project. Half of Richard Body's salary was paid by Manchester Metropolitan University during the study period.

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      Citation Excerpt :

      Fourth, even though chest pain radiating to the right arm, and especially to both arms, increased the risk of MACE, we found that the effect was small, unlike what has been suggested previously (4,6). Our results thereby confirm the studies by Body et al. and Fanaroff et al. (2,3). Associated symptoms, such as sweating, nausea, and vomiting, have also been reported to increase ACS probability, in contrast to our results (2,4,6,28).

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    A Spanish translated version of the summary of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2009.11.014.

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