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Chest pain in general practice: a systematic review of prediction rules

Ralf E Harskamp1,2, Simone C Laeven1, Jelle Cl Himmelreich1

  • 1Department of General Practice, Amsterdam UMC, University of Amsterdam, Amsterdam Public Health, Academic Medical Center, Amsterdam, The Netherlands.

BMJ Open
|March 2, 2019
PubMed

Insights

Clinical decision rules (CDRs) for chest pain in general practice are evaluated. The Marburg Heart Score shows promise for intermittent chest pain, outperforming clinical judgment, but no rule safely excludes acute coronary syndrome (ACS).

Area of Science:

  • Cardiology
  • General Practice
  • Diagnostic Accuracy

Background:

  • Chest pain is a common presentation in general practice.
  • Accurate diagnosis is crucial to rule out serious conditions like acute coronary syndrome (ACS).
  • Clinical decision rules (CDRs) may aid in diagnosis, but their performance in primary care needs assessment.

Purpose of the Study:

  • To systematically review and assess the performance of CDRs for chest pain in general practice.
  • To identify CDRs applicable in primary care without advanced testing.
  • To compare the diagnostic accuracy of CDRs against clinical judgment.

Main Methods:

  • Systematic review of diagnostic accuracy studies.
  • Searched Medline/PubMed, Embase, CINAHL, and Google Scholar up to October 2018.
  • Independent data extraction and quality assessment (QUADAS-2) by reviewers.

Main Results:

  • Five CDRs were identified across eight studies for intermittent chest pain and ACS rule-out.
  • The Marburg Heart Score demonstrated high sensitivity (86%-91%) and specificity (61%-81%) for coronary disease, outperforming general practitioner judgment.
  • CDRs for ACS rule-out showed variable performance; the Bruins Slot rule was safer than clinical judgment but had limitations.

Conclusions:

  • No current CDR can definitively rule out ACS in general practice.
  • For intermittent chest pain, the Marburg Heart Score is the most validated CDR and appears superior to clinical judgment alone.
  • Further validation is needed for other CDRs, particularly those for ACS rule-out.
Abstract

Keywords:
coronary heart diseasemedical historyprimary care

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