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Am Fam Physician. 2017;96(5):328

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Clinical Question

What elements of a patient's chest pain history are the best predictors for ruling in/out acute myocardial infarction (MI)?

Evidence-Based Answer

The most useful element for ruling in acute MI is chest pain with radiation to both arms, followed by radiation to the right arm. The most useful elements for ruling out acute MI are pleuritic chest pain, sharp pain, and pain reproduced by palpation. (Strength of Recommendation = A, based on two systematic reviews and one cohort study.)

Evidence Summary

A systematic review of 64 published studies and one unpublished study (N not reported) reviewed bedside diagnosis of MI in adults presenting to the emergency department with chest pain unrelated to trauma and unexplained by radiography.1 The diagnosis of acute MI was determined by elevated cardiac isoenzymes and electrocardiography (ECG) changes. Factors that most reliably predicted acute MI were pain radiation to the right arm or shoulder (sensitivity = 15% to 41%; specificity = 94% to 95%; positive likelihood ratio [LR+] = 4.7; 95% confidence interval [CI], 1.9 to 12) and radiation to the left arm (sensitivity = 34% to 55%; specificity = 76%; LR+ = 1.8; 95% CI, 1.1 to 2.8). Factors associated with a decreased likelihood included pleuritic pain (sensitivity = 3% to 6%; specificity = 74% to 82%; LR+ = 0.2; 95% CI, 0.2 to 0.3), sharp pain (sensitivity = 8% to 16%; specificity = 59% to 70%; LR+ = 0.3; 95% CI, 0.2 to 0.5), and positional pain (sensitivity = 3% to 11%; specificity = 75% to 87%; LR+ = 0.3; 95% CI, 0.2 to 0.5).

A systematic review of 14 studies (N = 32,241) compared elements of acute chest pain in patients presenting to the emergency department or admitted to the hospital for suspected MI.2 The diagnosis was determined by cardiac enzymes, ECG changes, or discharge diagnosis. Characteristics that most reliably predicted acute MI were pain radiation to both arms (LR+ = 7.1; 95% CI, 3.6 to 14), radiation to the right shoulder (LR+ = 2.9; 95% CI, 1.4 to 6.0), pain in the chest or left arm (LR+ = 2.7; CI not reported), and radiation to the left arm (LR+ = 2.3; 95% CI, 1.7 to 3.1). Factors associated with decreased likelihood included pleuritic chest pain (LR+ = 0.2; 95% CI, 0.2 to 0.3), pain reproduced by palpation (LR+ = 0.2 to 0.4; CI not reported), sharp or stabbing pain (LR+ = 0.3; 95% CI, 0.2 to 0.5), and positional pain (LR+ = 0.3; 95% CI, 0.2 to 0.4).

A prospective observational cohort study (N = 893) examined clinical features of acute MI in patients presenting to the large urban emergency department of a teaching hospital.3 The characteristic that most reliably predicted acute MI was pain radiation to both arms or shoulders (sensitivity = 38.2%; specificity = 90.6%; LR+ = 4.1; 95% CI, 2.5 to 6.5). The factor associated with a decreased likelihood was a tender chest wall (sensitivity = 92%; specificity = 28%; LR+ = 0.3; 95% CI, 0.1 to 1.1).

Copyright Family Physicians Inquiries Network. Used with permission.

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 (https://www.cebm.net).

The complete database of evidence-based questions and answers is copyrighted by FPIN. If interested in submitting questions or writing answers for this series, go to https://www.fpin.org or email:  questions@ fpin.org.

This series is coordinated by John E. Delzell Jr., MD, MSPH, associate medical editor.

A collection of FPIN’s Help Desk Answers published in AFP is available at https://www.aafp.org/afp/hda.

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