FPIN's Help Desk Answers
Diagnosis of Acute Coronary Syndrome
Am Fam Physician. 2018 Aug 1;98(3):online.
What is the best test to diagnose acute coronary syndrome (ACS) in patients who present to the emergency department with chest pain?
The best test to diagnose ACS is a risk score based on a clinical prediction rule such as the HEART (history, electrocardiography, age, risk factors, troponin level) or TIMI (Thrombolysis in Myocardial Infarction) risk score, which have positive likelihood ratios (LR+'s) of 13 and 6.8, respectively. (Strength of Recommendation: A, based on a meta-analysis of diagnostic cohort studies.)
A 2015 systematic review of 58 studies (N = 102,847) estimated the accuracy of individual factors in diagnosing ACS in patients of any age presenting to the emergency department with chest pain.1 The reference standard for diagnosis varied, but was commonly a discharge diagnosis of ACS or a cardiovascular event (cardiac death, myocardial infarction, or coronary revascularization) 14 to 42 days after presentation. Using only historical factors, the physician's overall clinical impression of definite ACS was moderately helpful for ruling in ACS (LR+ = 4.0; 95% confidence interval [CI], 2.5 to 6.6), but an impression of “definitely not” was not predictive. Useful risk factors included a previous abnormal stress test result (LR+ = 3.1; 95% CI, 2 to 4.7) and presence of peripheral arterial disease (LR+ = 2.7; 95% CI, 1.5 to 4.8). Significant symptoms included pain radiating to both arms (LR+ = 2.6; 95% CI, 1.8 to 3.7), pain similar to prior ischemia (LR+ = 2.2; 95% CI, 2 to 2.6), and change in pain pattern over the previous 24 hours (LR+ = 2.0; 95% CI, 1.6 to 2.5). The only significant physical examination finding was pain reproduced by palpation, which was helpful for ruling out ACS (negative likelihood ratio [LR–] = 1.2; 95% CI, 1.0 to 1.2). ST-segment depression on electrocardiography was helpful for ruling in ACS (LR+ = 5.3; 95% CI, 2.1 to 8.6).
Clinical prediction rules performed better than individual factors for ruling in and
1. Fanaroff AC, Rymer JA, Goldstein SA, Simel DL, Newby LK. Does this patient with chest pain have acute coronary syndrome? The rational clinical examination systematic review. JAMA. 2015;314(18):1955–1965.
2. Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the management of patients with non– ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines [published correction appears in J Am Coll Cardiol. 2014;64(24):2713–2714]. J Am Coll Cardiol. 2014;64(24):e139–e228.
Help Desk Answers provides answers to questions submitted by practicing family physicians to the Family Physicians Inquiries Network (FPIN). Members of the network select questions based on their relevance to family medicine. Answers are drawn from an approved set of evidence-based resources and undergo peer review. The strength of recommendations and the level of evidence for individual studies are rated using criteria developed by the Evidence-Based Medicine Working Group (http://www.cebm.net).
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