Every year there are 6 million visits to the Emergency Department (ED) for chest pain, and approximately 2 million hospital admissions each year.1 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).2 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.
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 Dec;58(6):501-7. PMID: 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.
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.
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.
CP characteristics that DECREASE likelihood of ACS/AMI:
CP characteristics that INCREASE likelihood of ACS/AMI:
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.
Panju AA, Hemmelgarn BR, Guyatt GH, Simel DL. The rational clinical examination. Is this patient having a myocardial infarction? JAMA. 1998 Oct 14;280(14):1256-63. PMID: 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).
Features that INCREASE the Probability of a AMI
Features that DECREASE the Probability of an AMI
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.