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Published in: BMC Emergency Medicine 1/2014

Open Access 01-12-2014 | Research article

What decides the suspicion of acute coronary syndrome in acute chest pain patients?

Authors: Alexander Kamali, Martin Söderholm, Ulf Ekelund

Published in: BMC Emergency Medicine | Issue 1/2014

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Abstract

Background

Physicians assessing chest pain patients in the emergency department (ED) base the likelihood of acute coronary syndrome (ACS) mainly on ECG, symptom history and blood markers of myocardial injury. Among these, the ECG has been stated to be the most important diagnostic tool. We aimed to analyze the relative contributions of these three diagnostic modalities to the ED physicians’ evaluation of ACS likelihood in clinical practice.

Methods

1151 consecutive ED chest pain patients were prospectively included. The ED physician’s subjective assessment of the patient’s likelihood of ACS (obvious ACS, strong, vague or no suspicion of ACS), the symptoms and the ECG were recorded on a special form. The ED TnT value was retrieved from the medical records. Frequency tables and logistic regression models were used to evaluate the contributions of the diagnostic tests to the level of ACS suspicion.

Results

Symptoms determined whether the physician had any suspicion of ACS (odds ratio, OR 526 for symptoms typical compared to not suspicious of ACS) since neither ECG nor TnT contributed significantly (ORs not significantly different from 1) to this assessment. ACS was suspected in only one in ten patients with symptoms not suspicious of ACS. Symptoms were also more important (OR 620 for typical symptoms) than ECG (OR 31 for ischemic ECG) and TnT (OR 3.4 for a positive TnT) for the assessment of obvious ACS/strong suspicion versus vague/no suspicion. Of the patients with ST-elevation on ECG, 71% were considered to have an obvious ACS, as opposed to only 6% of those with symptoms typical of ACS and 10% of those with a positive TnT.

Conclusion

The ED physicians used symptoms as the most important assessment tool and applied primarily the symptoms to determine the level of ACS suspicion and to rule out ACS. The ECG was primarily used to rule in ACS. The TnT level played a minor role for the assessment of ACS likelihood. Further studies regarding ACS prediction based on symptoms may help improve decision-making in ED patients with possible ACS.
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Literature
1.
go back to reference Ekelund U, Nilsson HJ, Frigyesi A, Torffvit O: Patients with suspected acute coronary syndrome in a university hospital emergency department: an observational study. BMC Emerg Med. 2002, 2 (1): 1-10.1186/1471-227X-2-1.CrossRefPubMedPubMedCentral Ekelund U, Nilsson HJ, Frigyesi A, Torffvit O: Patients with suspected acute coronary syndrome in a university hospital emergency department: an observational study. BMC Emerg Med. 2002, 2 (1): 1-10.1186/1471-227X-2-1.CrossRefPubMedPubMedCentral
2.
go back to reference The National board of health and Welfare (Socialstyrelsen): Kranskärlssjukdom: (Guideline) Vetenskapligt Underlag för Nationella Riktlinjer för Hjärtsjukvård. 2008, 42- The National board of health and Welfare (Socialstyrelsen): Kranskärlssjukdom: (Guideline) Vetenskapligt Underlag för Nationella Riktlinjer för Hjärtsjukvård. 2008, 42-
3.
go back to reference Ernfridsson M, Ekelund U: ABC om misstänkt akut koronart syndrom. Lakartidningen. 2005, 102: 28-29. Ernfridsson M, Ekelund U: ABC om misstänkt akut koronart syndrom. Lakartidningen. 2005, 102: 28-29.
4.
go back to reference Lee TH, Goldman L: Evaluation of the patient with acute chest pain. N Engl J Med. 2000, 342 (16): 1187-1195. 10.1056/NEJM200004203421607.CrossRefPubMed Lee TH, Goldman L: Evaluation of the patient with acute chest pain. N Engl J Med. 2000, 342 (16): 1187-1195. 10.1056/NEJM200004203421607.CrossRefPubMed
5.
go back to reference Goldman L, Kirtane AJ: Triage of patients with acute chest pain and possible cardiac ischemia: the elusive search for diagnostic perfection. Ann Intern Med. 2003, 139 (12): 987-995. 10.7326/0003-4819-139-12-200312160-00008.CrossRefPubMed Goldman L, Kirtane AJ: Triage of patients with acute chest pain and possible cardiac ischemia: the elusive search for diagnostic perfection. Ann Intern Med. 2003, 139 (12): 987-995. 10.7326/0003-4819-139-12-200312160-00008.CrossRefPubMed
6.
go back to reference Goodacre S, Locker T, Morris F, Campbell S: How useful are clinical features in the diagnosis of acute, undifferentiated chest pain?. Acad Emerg Med. 2002, 9 (3): 203-208. 10.1111/j.1553-2712.2002.tb00245.x.CrossRefPubMed Goodacre S, Locker T, Morris F, Campbell S: How useful are clinical features in the diagnosis of acute, undifferentiated chest pain?. Acad Emerg Med. 2002, 9 (3): 203-208. 10.1111/j.1553-2712.2002.tb00245.x.CrossRefPubMed
7.
go back to reference Panju AA1, Hemmelgarn BR, Guyatt GH, Simel DL: The rational clinical examination. Is this patient having a myocardial infarction?. JAMA. 1998, 280 (14): 1256-1263. 10.1001/jama.280.14.1256.CrossRefPubMed Panju AA1, Hemmelgarn BR, Guyatt GH, Simel DL: The rational clinical examination. Is this patient having a myocardial infarction?. JAMA. 1998, 280 (14): 1256-1263. 10.1001/jama.280.14.1256.CrossRefPubMed
8.
go back to reference Bruyninckx R, Aertgeerts B, Bruyninckx P, Buntinx F: Signs and symptoms in diagnosing acute myocardial infarction and acute coronary syndrome: a diagnostic meta-analysis. Br J Gen Pract. 2008, 58 (547): 105-111.CrossRefPubMed Bruyninckx R, Aertgeerts B, Bruyninckx P, Buntinx F: Signs and symptoms in diagnosing acute myocardial infarction and acute coronary syndrome: a diagnostic meta-analysis. Br J Gen Pract. 2008, 58 (547): 105-111.CrossRefPubMed
9.
go back to reference Swap CJ, Nagurney JT: Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes. Jama. 2005, 294 (20): 2623-2629. 10.1001/jama.294.20.2623.CrossRefPubMed Swap CJ, Nagurney JT: Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes. Jama. 2005, 294 (20): 2623-2629. 10.1001/jama.294.20.2623.CrossRefPubMed
10.
go back to reference Bassan R, Bassan R, Scofano M, Gamarski R, Fernando H, Pimenta L, Volschan A, Araujo M, Clare C, Fabrício M, Sanmartin CH, Mohallem K, Gaspar S, Macaciel R: Chest pain in the emergency room. Importance of a systematic approach. Arq Bras Cardiol. 2000, 74 (1): 13-29.CrossRef Bassan R, Bassan R, Scofano M, Gamarski R, Fernando H, Pimenta L, Volschan A, Araujo M, Clare C, Fabrício M, Sanmartin CH, Mohallem K, Gaspar S, Macaciel R: Chest pain in the emergency room. Importance of a systematic approach. Arq Bras Cardiol. 2000, 74 (1): 13-29.CrossRef
11.
go back to reference Swap C, Nagurney J: Patients with suspected acute coronary syndrome in a university hospital emergency department: an observational study. American Medical Association. 2002, 2 (1): 1-7. Swap C, Nagurney J: Patients with suspected acute coronary syndrome in a university hospital emergency department: an observational study. American Medical Association. 2002, 2 (1): 1-7.
12.
go back to reference Kontos MC, Jesse RL: Evaluation of the emergency department chest pain patient. Am J Cardiol. 2000, 85 (5A): 32B-39B.CrossRefPubMed Kontos MC, Jesse RL: Evaluation of the emergency department chest pain patient. Am J Cardiol. 2000, 85 (5A): 32B-39B.CrossRefPubMed
13.
go back to reference Edwards M, Chang AM, Matsuura AC, Green M, Robey JM, Hollander JE: Relationship between pain severity and outcomes in patients presenting with potential acute coronary syndromes. Ann Emerg Med. 2011, 58 (6): 501-507. 10.1016/j.annemergmed.2011.05.036.CrossRefPubMed Edwards M, Chang AM, Matsuura AC, Green M, Robey JM, Hollander JE: Relationship between pain severity and outcomes in patients presenting with potential acute coronary syndromes. Ann Emerg Med. 2011, 58 (6): 501-507. 10.1016/j.annemergmed.2011.05.036.CrossRefPubMed
14.
go back to reference Pope JH, Selker HP: Diagnosis of acute cardiac ischemia. Emerg Med Clin North Am. 2003, 21 (1): 27-59. 10.1016/S0733-8627(02)00079-2.CrossRefPubMed Pope JH, Selker HP: Diagnosis of acute cardiac ischemia. Emerg Med Clin North Am. 2003, 21 (1): 27-59. 10.1016/S0733-8627(02)00079-2.CrossRefPubMed
15.
go back to reference Green GB, Hill PM: Approach to Chest Pain. Emergency Medicine. A Comprehensive Study Guide. Edited by: Tintinalli JE, Kelen GD, Stapczynski JS. 2004, New York, NY: McGraw-Hill, 333-343. Green GB, Hill PM: Approach to Chest Pain. Emergency Medicine. A Comprehensive Study Guide. Edited by: Tintinalli JE, Kelen GD, Stapczynski JS. 2004, New York, NY: McGraw-Hill, 333-343.
16.
go back to reference Lin KB, Kathy B, Lin BA, Shofer F, McCusker C, Meshberg E, Hollander J: Predictive value of T-wave abnormalities at the time of emergency department presentation in patients with potential acute coronary syndromes. Acad Emerg Med. 2008, 15 (6): 537-543. 10.1111/j.1553-2712.2008.00135.x.CrossRefPubMed Lin KB, Kathy B, Lin BA, Shofer F, McCusker C, Meshberg E, Hollander J: Predictive value of T-wave abnormalities at the time of emergency department presentation in patients with potential acute coronary syndromes. Acad Emerg Med. 2008, 15 (6): 537-543. 10.1111/j.1553-2712.2008.00135.x.CrossRefPubMed
17.
go back to reference Sharkey S, Berger C, Brunette D, Henry T: Impact of the electrocardiogram on the delivery of thrombolytic therapy for acute myocardial infarction. Am J Cardiol. 1994, 73 (8): 550-553. 10.1016/0002-9149(94)90331-X.CrossRefPubMed Sharkey S, Berger C, Brunette D, Henry T: Impact of the electrocardiogram on the delivery of thrombolytic therapy for acute myocardial infarction. Am J Cardiol. 1994, 73 (8): 550-553. 10.1016/0002-9149(94)90331-X.CrossRefPubMed
18.
go back to reference Wagner G: Marriott’s Practical Electrocardiography. Edited by: Wilkins LW. 2008, Philadephia, 145-162. 11 Wagner G: Marriott’s Practical Electrocardiography. Edited by: Wilkins LW. 2008, Philadephia, 145-162. 11
19.
go back to reference Zhou S: An automated algorithm to improve ECG detection of posterior STEMI associated with left circumflex coronary artery occlusion. Comput Cardiol. 2006, 33: 33-36. Zhou S: An automated algorithm to improve ECG detection of posterior STEMI associated with left circumflex coronary artery occlusion. Comput Cardiol. 2006, 33: 33-36.
20.
go back to reference Thygesen K, Alpert J, White H: Universal definition of myocardial infarction. Circulation. 2007, 116 (22): 2634-2653. 10.1161/CIRCULATIONAHA.107.187397.CrossRefPubMed Thygesen K, Alpert J, White H: Universal definition of myocardial infarction. Circulation. 2007, 116 (22): 2634-2653. 10.1161/CIRCULATIONAHA.107.187397.CrossRefPubMed
21.
go back to reference Alpert JS, Antman E, Bassand JP, Klein W, Ohman M, Lopes Sendon J, Rydén L, Simoons M, Tendera M: Myocardial infarction redefined–a consensus document of the joint European society of cardiology/American college of cardiology committee for the redefinition of myocardial infarction. J Am Coll Cardiol. 2000, 36 (3): 959-969. 10.1016/S0735-1097(00)00804-4.CrossRefPubMed Alpert JS, Antman E, Bassand JP, Klein W, Ohman M, Lopes Sendon J, Rydén L, Simoons M, Tendera M: Myocardial infarction redefined–a consensus document of the joint European society of cardiology/American college of cardiology committee for the redefinition of myocardial infarction. J Am Coll Cardiol. 2000, 36 (3): 959-969. 10.1016/S0735-1097(00)00804-4.CrossRefPubMed
22.
go back to reference Luepker RV, Luepker R, Apple F, Christenson R, Crow R, Fortmann S, Goff D, Goldberg R, Hand M, Jaffe A, Julian D, Levy D, Manolio T, Mendis S, Mensah G, Pajak A, Prineas R, Reddy S, Roger V, Rosamond W, Shahar E, Sharrett R, Sorlie P, Tunstall-Pedoe H: Case definitions for acute coronary heart disease in epidemiology and clinical research studies: a statement from the AHA council on epidemiology and prevention; AHA statistics committee; world heart federation council on epidemiology and prevention; the European society of cardiology working group on epidemiology and prevention; centers for disease control and prevention; and the national heart, lung, and blood institute. Circulation. 2003, 108 (20): 2543-2549. 10.1161/01.CIR.0000100560.46946.EA.CrossRefPubMed Luepker RV, Luepker R, Apple F, Christenson R, Crow R, Fortmann S, Goff D, Goldberg R, Hand M, Jaffe A, Julian D, Levy D, Manolio T, Mendis S, Mensah G, Pajak A, Prineas R, Reddy S, Roger V, Rosamond W, Shahar E, Sharrett R, Sorlie P, Tunstall-Pedoe H: Case definitions for acute coronary heart disease in epidemiology and clinical research studies: a statement from the AHA council on epidemiology and prevention; AHA statistics committee; world heart federation council on epidemiology and prevention; the European society of cardiology working group on epidemiology and prevention; centers for disease control and prevention; and the national heart, lung, and blood institute. Circulation. 2003, 108 (20): 2543-2549. 10.1161/01.CIR.0000100560.46946.EA.CrossRefPubMed
23.
go back to reference Granger CB, Granger C, Goldberg J, Dabbous O, Pieper K, Eagle K, Cannon C, Van de Werf F, Avezum A, Goodman S, Flather M, Keith A: Predictors of hospital mortality in the global registry of acute coronary events. Arch Intern Med. 2003, 163 (19): 2345-2353. 10.1001/archinte.163.19.2345.CrossRefPubMed Granger CB, Granger C, Goldberg J, Dabbous O, Pieper K, Eagle K, Cannon C, Van de Werf F, Avezum A, Goodman S, Flather M, Keith A: Predictors of hospital mortality in the global registry of acute coronary events. Arch Intern Med. 2003, 163 (19): 2345-2353. 10.1001/archinte.163.19.2345.CrossRefPubMed
24.
go back to reference Brieger D, Fox K, FitzGerald G, Eagle KA, Budaj A, Avezum A, Granger CB, Costa B, Anderson FA, Steg PG: Predicting freedom from clinical events in non-ST-elevation acute coronary syndromes: the global registry of acute coronary events. Heart. 2009, 95 (11): 888-894. 10.1136/hrt.2008.153387.CrossRefPubMed Brieger D, Fox K, FitzGerald G, Eagle KA, Budaj A, Avezum A, Granger CB, Costa B, Anderson FA, Steg PG: Predicting freedom from clinical events in non-ST-elevation acute coronary syndromes: the global registry of acute coronary events. Heart. 2009, 95 (11): 888-894. 10.1136/hrt.2008.153387.CrossRefPubMed
25.
go back to reference Soderholm M, Malekian Deligani M, Choudhary M, Bjork J, Ekelund U: Ability of risk scores to predict a low complication risk in patients admitted for suspected acute coronary syndrome. Emerg Med J. 2011, Epub ahead of print Soderholm M, Malekian Deligani M, Choudhary M, Bjork J, Ekelund U: Ability of risk scores to predict a low complication risk in patients admitted for suspected acute coronary syndrome. Emerg Med J. 2011, Epub ahead of print
26.
go back to reference Gupta M, Tabas JA, Kohn MA: Presenting complaint among patients with myocardial infarction who present to an urban, public hospital emergency department. Ann Emerg Med. 2002, 40 (2): 180-186. 10.1067/mem.2002.126396.CrossRefPubMed Gupta M, Tabas JA, Kohn MA: Presenting complaint among patients with myocardial infarction who present to an urban, public hospital emergency department. Ann Emerg Med. 2002, 40 (2): 180-186. 10.1067/mem.2002.126396.CrossRefPubMed
27.
go back to reference Steurer J, Held U, Schmid D, Ruckstuhl J, Bachmann L: Clinical value of diagnostic instruments for ruling out acute coronary syndrome in patients with chest pain: a systematic review. Emerg Med J. 2010, 27 (12): 896-902. 10.1136/emj.2010.092619.CrossRefPubMed Steurer J, Held U, Schmid D, Ruckstuhl J, Bachmann L: Clinical value of diagnostic instruments for ruling out acute coronary syndrome in patients with chest pain: a systematic review. Emerg Med J. 2010, 27 (12): 896-902. 10.1136/emj.2010.092619.CrossRefPubMed
28.
go back to reference Kennedy RL, Fraser H, McStay L, Harrison R: Early diagnosis of acute myocardial infarction using clinical and electrocardiographic data at presentation: derivation and evaluation of logistic regression models. Eur Heart J. 1996, 17 (8): 1181-1191. 10.1093/oxfordjournals.eurheartj.a015035.CrossRefPubMed Kennedy RL, Fraser H, McStay L, Harrison R: Early diagnosis of acute myocardial infarction using clinical and electrocardiographic data at presentation: derivation and evaluation of logistic regression models. Eur Heart J. 1996, 17 (8): 1181-1191. 10.1093/oxfordjournals.eurheartj.a015035.CrossRefPubMed
29.
go back to reference Clinical policy: critical issues in the evaluation and management of adult patients presenting with suspected acute myocardial infarction or unstable angina: American college of emergency physicians. Ann Emerg Med. 2000, 35 (5): 521-525.CrossRefPubMed Clinical policy: critical issues in the evaluation and management of adult patients presenting with suspected acute myocardial infarction or unstable angina: American college of emergency physicians. Ann Emerg Med. 2000, 35 (5): 521-525.CrossRefPubMed
30.
go back to reference Hollander JE: Highly sensitive troponins the answer or just more questions?. J Am Coll Cardiol. 2009, 54 (13): 1173-1175. 10.1016/j.jacc.2009.05.052.CrossRefPubMed Hollander JE: Highly sensitive troponins the answer or just more questions?. J Am Coll Cardiol. 2009, 54 (13): 1173-1175. 10.1016/j.jacc.2009.05.052.CrossRefPubMed
31.
go back to reference Peacock WF: The value of nothing: the consequence of a negative troponin test. J Am Coll Cardiol. 58 (13): 1340-1342. Peacock WF: The value of nothing: the consequence of a negative troponin test. J Am Coll Cardiol. 58 (13): 1340-1342.
32.
go back to reference Giannitsis E, Becker M, Kurz K, Hess G, Zdunek D, Katus H: High-sensitivity cardiac troponin T for early prediction of evolving non-ST-segment elevation myocardial infarction in patients with suspected acute coronary syndrome and negative troponin results on admission. Clin Chem. 56 (4): 642-650. Giannitsis E, Becker M, Kurz K, Hess G, Zdunek D, Katus H: High-sensitivity cardiac troponin T for early prediction of evolving non-ST-segment elevation myocardial infarction in patients with suspected acute coronary syndrome and negative troponin results on admission. Clin Chem. 56 (4): 642-650.
33.
go back to reference Olsson S-E, Olsson SE, Ohlsson M, Ohlin H, Dzaferagic S, Nilsson ML, Sandkull P, Edebnbrandt L, Olsson SE, Ohlsson M, Ohlin H, Dzaferagic S, Nilsson ML, Sandkull P, Edebnbrandt L: Decision support for the initial triage of patients with acute coronary syndromes. Clin Physiol Funct Imaging. 2006, 26: 151-156. 10.1111/j.1475-097X.2006.00669.x.CrossRefPubMed Olsson S-E, Olsson SE, Ohlsson M, Ohlin H, Dzaferagic S, Nilsson ML, Sandkull P, Edebnbrandt L, Olsson SE, Ohlsson M, Ohlin H, Dzaferagic S, Nilsson ML, Sandkull P, Edebnbrandt L: Decision support for the initial triage of patients with acute coronary syndromes. Clin Physiol Funct Imaging. 2006, 26: 151-156. 10.1111/j.1475-097X.2006.00669.x.CrossRefPubMed
34.
go back to reference Forberg JL, Forberg J, Green M, Bjork J, Ohlsson M, Edenbrandt L, Ohlin H, Ekelund U: In search of the best method to predict acute coronary syndrome using only the electrocardiogram from the emergency department. J Electrocardiol. 2009, 42 (1): 58-63. 10.1016/j.jelectrocard.2008.07.010.CrossRefPubMed Forberg JL, Forberg J, Green M, Bjork J, Ohlsson M, Edenbrandt L, Ohlin H, Ekelund U: In search of the best method to predict acute coronary syndrome using only the electrocardiogram from the emergency department. J Electrocardiol. 2009, 42 (1): 58-63. 10.1016/j.jelectrocard.2008.07.010.CrossRefPubMed
35.
go back to reference Heden B, Hedén B, Ohlin H, Rittner R, Edenbrandt L: Acute myocardial infarction detected in the 12-lead ECG by artificial neural networks. Circulation. 1997, 96 (6): 1798-1802. 10.1161/01.CIR.96.6.1798.CrossRefPubMed Heden B, Hedén B, Ohlin H, Rittner R, Edenbrandt L: Acute myocardial infarction detected in the 12-lead ECG by artificial neural networks. Circulation. 1997, 96 (6): 1798-1802. 10.1161/01.CIR.96.6.1798.CrossRefPubMed
Metadata
Title
What decides the suspicion of acute coronary syndrome in acute chest pain patients?
Authors
Alexander Kamali
Martin Söderholm
Ulf Ekelund
Publication date
01-12-2014
Publisher
BioMed Central
Published in
BMC Emergency Medicine / Issue 1/2014
Electronic ISSN: 1471-227X
DOI
https://doi.org/10.1186/1471-227X-14-9

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