Chest Pain: What is the Value of a Good History?

01 Nov
November 1, 2013

Chest Pain HistoryEvery year there are 6 million visits to the Emergency Department (ED) for chest pain, and approximately 2 million hospital admissions each year.  This is approximately about 10% of ED visits and 25% of hospital admissions with 85% of these admissions receiving a diagnosis of a non-ischemic etiology to their chest pain (CP).  This over triage has enormous economic implications for the US health care system estimated at $8 billion in annual costs.

Why do we do this?

Well, it could be that the single greatest contributor to financial losses in malpractice claims against emergency physicians comes from failure to accurately diagnose acute myocardial infarction (AMI).

So the question is:

Are there specific aspects of the history that can increase or decrease the likelihood that a patient has acute coronary syndrome (ACS) and/or AMI?

There are 5 studies that were recommended by Dr. Amal Mattu, on his EMCast Podcast (July 2012) that evaluated the components of history that were more likely to correlate with ACS and/or AMI. Each will be reviewed below.

Study Number of Patients
Edwards et al., 2011 3306
Body et al., 2010 796
Swap et al., 2005 Literature Review
Goodacre et al., 2002 893
Panju et al. , 1998 Literature Review

 (21802776)

The main objective was to see if there was any correlation between severity of CP and the risk of AMI at presentation, or composite end points (death, revascularization, or acute myocardial infarction) at 30 days. Severe chest pain was defined as 9 – 10 on a pain scale of 0 to 10.

  • Risk of AMI with Pain Score of 1 – 8 (82% of patients) = 3.0%
  • Risk of AMI with Pain Score of 9 – 10 (18% of patients) = 3.9%
  • Not statistically significant different
  • Bottom Line:  Severity of pain is not related to likelihood of AMI at presentation, or composite end points (death, revascularization, or AMI) at 30 days.

 (20036454)

The objective was to assessing the value of individual symptoms for predicting a diagnosis of AMI or the occurrence of adverse events (death, AMI, revascularization via PCI or CABG) within 6 months.
  • Strongest positive predictor of AMI
    • Diaphoresis with CP
  • Other positive predictors of AMI and adverse events
    • Nausea and vomiting with CP
    • CP with radiation to both shoulders > right shoulder > left shoulder
    • Central chest pain
  • Strongest negative predictor of AMI
    • Pain located in the left anterior chest
  • Other negative predictors of AMI and adverse events
    • CP described as pain being the same as previous AMI
    • Presence of CP at rest
  • Bottom Line:  Many “atypical” symptoms are more likely to render the diagnosis of ACS than traditional “typical” symptoms

The authors wanted to identify the elements of a CP history that might be most helpful to the clinician in identifying ACS. They performed a literature search from 1970 to 2005.

Screen Shot 2013-06-01 at 12.51.03 AM
  • Bottom Line: No characteristics of chest pain alone, or in combination, identify a group of patients that can be safely discharge home without further diagnostic testing. Also beware the chest pain which radiates to the RIGHT shoulder (LR = 4.7).

(11874776)

In this prospective, observation cohort study of 893 patients, the authors assessed the performance of clinical features used in the diagnosis of CP, specifically in patients who were clinically stable and had a non-diagnostic EKG.

  •  Predictive of ACS/AMI:
    • Exertional pain
    • Pain radiating to both arms > right arm
  •  NOT predictive of ACS/AMI:
    • Presence of chest wall tenderness
    • Nausea or vomiting
    • Diaphoresis
  • Bottom Line:  Clinical features have a limited role in triage decision-making for ACS/AMI.

(9786377)

The final study is an oldie but a goodie. The authors aimed to identify clinical features that would increase or decrease the probability of an AMI, presenting with acute chest pain by reviewing the literature (1980-1991).
Screen Shot 2013-06-01 at 12.51.10 AM
  •  Bottom Line:  History alone can help, but can NOT rule out ACS/AMI!

SUMMARY

Clinical factors that INCREASE likelihood of ACS/AMI:
  1. CP radiating bilaterally > right > left
  2. Diaphoresis associated with CP
  3. N/V associated with CP
  4. Pain with exertion

Clinical factors that DECREASE likelihood of ACS/AMI:
Chest pain that is:

  1. Pleuritic
  2. Positional
  3. Sharp, stabbing
  4. Reproducible with palpation
These were all fantastic articles looking at aspects of the history in helping aide us in clinical decision making, but none of these historical elements alone or in combination can reliably help us rule in or rule out ACS or AMI.  Just remember that there are some historical elements (with negative and positive likelihood ratios) that we need to ask our patients to assist in risk stratification in conjunction with an EKG and cardiac biomarkers.
 

Bibliography

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Salim Rezaie

Clinical Associate Professor of EM and IM at University of Texas Health Science Center at San Antonio (UTHSCSA)
Creator & Founder of R.E.B.E.L. EM
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4 replies
  1. Dustin Sahraie says:

    Very insightful! What do you think about using clinical-decision rules like EDACS after taking a history to guide CP management?
    http://www.mdcalc.com/emergency-department-assessment-chest-pain-score-edacs/

    Reply
    • Salim Rezaie says:

      Hello Dustin,
      TY For reading….currently I am using the HEART score, as I find it more user friendly. The issue with scores like EDACS and Grace is they are so complicated I always have to look them up or use a calculator tool. EDACS has not been externally validated at this point nor is it recommended in the AHA guidelines. I would be careful putting much weight on this. I am all for using clinical decision rules to help with stratification for disposition, but do not feel there is enough evidence to support EDACS at this time. Hope that helps.

      Salim

      Reply

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  1. […] We have already discussed the value of a good history in assessing patients with chest pain on REBEL EM. What is known about chest pain is that it is a common complaint presenting to EDs all over the […]

  2. […] REBEL EM Summary of Studies and LR for CP features […]

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