Clinical paperThe value of symptoms and signs in the emergent diagnosis of acute coronary syndromes☆
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.
References (22)
- et al.
A neural computational aid to the diagnosis of acute myocardial infarction
Annals of Emergency Medicine
(2002) - et al.
Triage of patients for a rapid (5-minute) electrocardiogram: a rule based on presenting chief complaints
Annals of Emergency Medicine
(2000) - et al.
Is the radiation of chest pain a useful indicator of myocardial infarction? A prospective study of 541 patients
Accident & Emergency Nursing
(2002) - et al.
Prevalence of atypical chest pain descriptions in a population from the southern United States
The American Journal of the Medical Sciences
(1999) - et al.
ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-st-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines (writing committee to revise the 2002 guidelines for the management of patients with unstable angina/non-st-elevation myocardial infarction) developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine
Journal of the American College of Cardiology
(2007) - et al.
Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes. The Task Force for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes of the European Society of Cardiology
European Heart Journal
(2007) - et al.
The rational clinical examination: is this patient having a myocardial infarction
JAMA
(1998) - et al.
Signs and symptoms in diagnosing acute myocardial infarction and acute coronary syndrome: a diagnostic meta-analysis
British Journal of General Practice
(2008) - et al.
Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes
Journal of the American Medical Association
(2005) - et al.
Bedside diagnosis of coronary artery disease: a systematic review
American Journal of Medicine
(2004)
Clinical predictors of acute coronary syndromes in patients with undifferentiated chest pain
QJM
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2020, Journal of Emergency MedicineCitation 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.