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Published on: August 9, 2024
Bedside diagnosis of coronary artery disease: a systematic review
Andrea Akita Chun1, Steven R McGee
1Department of General Internal Medicine, University of Washington, Harborview Medical Center, Seattle 98104-2499, USA. anchun@u.washington.edu
Insights
Bedside findings accurately diagnose coronary artery disease and myocardial infarction, with typical angina and ECG changes being key indicators. Patient history and pain characteristics are crucial for diagnosis in different clinical settings.
Area of Science:
- Cardiology
- Diagnostic Medicine
Background:
- Coronary artery disease (CAD) and acute myocardial infarction (MI) are leading causes of mortality worldwide.
- Accurate and timely diagnosis is essential for effective patient management and improved outcomes.
Purpose of the Study:
- To evaluate the diagnostic accuracy of bedside clinical findings for coronary artery disease (CAD) and acute myocardial infarction (MI).
- To identify the most reliable clinical predictors in different patient presentations.
Main Methods:
- A comprehensive literature search of MEDLINE was conducted for studies published between January 1966 and January 2003.
- Articles focused on the bedside diagnosis of coronary disease and myocardial infarction in adult patients were included.
Main Results:
- For stable, intermittent chest pain, typical angina (LR=5.8), high cholesterol (LR=4.0), prior MI (LR=3.8), and age >70 (LR=2.6) predicted CAD.
- For acute chest pain, new ST elevation (LR=22), new Q waves (LR=22), and new ST depression (LR=4.5) strongly predicted MI.
- Conversely, nonanginal pain, prolonged pain duration, normal ECG, chest wall tenderness, and pleuritic/sharp/positional pain argued against these diagnoses.
Conclusions:
- The diagnostic utility of bedside findings is context-dependent.
- Patient-reported pain characteristics are paramount in diagnosing stable CAD.
- Electrocardiogram (ECG) findings are the most critical bedside predictors for diagnosing acute MI.
- Traditional risk factors, except extreme cholesterol levels, had minimal impact on diagnostic probability.
Purpose:
To assess the accuracy of bedside findings for diagnosing coronary artery disease and acute myocardial infarction.
Methods:
A MEDLINE search was performed to retrieve articles published from January 1966 to January 2003 that were relevant to the bedside diagnosis of coronary disease in adults.
Results:
In patients with stable, intermittent chest pain, the most useful bedside predictors for a diagnosis of coronary disease were found to be the presence of typical angina (likelihood ratio [LR]=5.8; 95% confidence interval [CI]: 4.2 to 7.8), serum cholesterol level >300 mg/dL (LR=4.0; 95% CI: 2.5 to 6.3), history of prior myocardial infarction (LR=3.8; 95% CI: 2.1 to 6.8), and age >70 years (LR=2.6; 95% CI: 1.8 to 4.0). Nonanginal chest pain (LR=0.1; 95% CI: 0.1 to 0.2), pain duration >30 minutes (LR=0.1; 95% CI: 0.0 to 0.9), and intermittent dysphagia (LR=0.2; 95% CI: 0.1 to 0.8) argued against a diagnosis of coronary disease. In patients with acute chest pain, the most important bedside predictors for a diagnosis of myocardial infarction were new ST elevation (LR=22; 95% CI: 16 to 30), new Q waves (LR=22; 95% CI: 7.6 to 62), and new ST depression (LR=4.5; 95% CI: 3.6 to 5.6). A normal electrocardiogram (LR=0.2; 95% CI: 0.1 to 0.3), chest wall tenderness (LR=0.3; 95% CI: 0.2 to 0.4), and pain that was pleuritic (LR=0.2; 95% CI: 0.2 to 0.3), sharp (LR=0.3; 95% CI: 0.2 to 0.5), or positional (LR=0.3; 95% CI: 0.2 to 0.5) argued against the diagnosis of myocardial infarction.
Conclusion:
The accuracy of bedside predictors depends on the clinical setting. In the evaluation of stable, intermittent chest pain, a patient's description of pain was found to be the most important predictor of underlying coronary disease. In the evaluation of acute chest pain, the electrocardiogram was the most useful bedside predictor for a diagnosis of myocardial infarction. Aside from the extremes in cholesterol values, the analysis of traditional risk factors changed the probability of coronary disease or myocardial infarction very little or not at all.
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