Diagnostic Accuracy of History and Physical Examination for Predicting Major Adverse Cardiac Events Within 30 Days in
David Eriksson1, Ardavan Khoshnood1, David Larsson2
1Department of Internal and Emergency Medicine, Lund University, Skåne University Hospital, Lund, Sweden.
Insights
Certain chest pain characteristics, like brief episodes or prolonged duration, significantly reduce the risk of major adverse cardiac events (MACE) in emergency department patients. These findings aid in ruling out MACE when present.
Area of Science:
- Cardiology
- Emergency Medicine
- Diagnostic Accuracy
Background:
- Standard acute coronary syndrome (ACS) assessment relies on history, physical exam, ECG, and troponins.
- Prior studies on diagnostic elements have yielded inconsistent results.
Purpose of the Study:
- To assess the diagnostic and prognostic accuracy of patient history and physical examination findings.
- To predict major adverse cardiac events (MACE) within 30 days in emergency department (ED) chest pain patients.
Main Methods:
- Prospective observational study of 1167 ED patients with nontraumatic chest pain.
- Clinical data collected during initial ED assessment.
- Primary outcome: 30-day MACE.
Main Results:
- Episodic chest pain lasting seconds (LR+ 0.0) and >24 hours (LR+ 0.1) markedly decreased 30-day MACE risk.
- Pulmonary rales (LR+ 3.0) increased risk; pain reproduced by palpation (LR+ 0.3) decreased risk.
- History of diabetes (LR+ 3.0) and peripheral arterial disease (LR+ 2.7) were most predictive.
Conclusions:
- No single clinical finding reliably ruled in 30-day MACE.
- Episodic chest pain (seconds) and prolonged chest pain (>24 hours) can help rule out 30-day MACE.
Background:
The cornerstones in the assessment of emergency department (ED) patients with suspected acute coronary syndrome (ACS) are patient history and physical examination, electrocardiogram, and cardiac troponins. Although there are several prior studies on this subject, they have in some cases produced inconsistent results.
Objective:
The aim of this study was to evaluate the diagnostic and prognostic accuracy of elements of patient history and the physical examination in ED chest pain patients for predicting major adverse cardiac events (MACE) within 30 days.
Methods:
This was a prospective observational study that included 1167 ED patients with nontraumatic chest pain. We collected clinical data during the initial ED assessment of the patients. Our primary outcome was 30-day MACE.
Results:
Pain radiating to both arms increased the probability of 30-day MACE (positive likelihood ratio [LR+] 2.7), whereas episodic chest pain lasting seconds (LR+ 0.0) and >24 h (LR+ 0.1) markedly decreased the risk. In the physical examination, pulmonary rales (LR+ 3.0) increased the risk of 30-day MACE, while pain reproduced by palpation (LR+ 0.3) decreased the risk. Among cardiac risk factors, a history of diabetes (LR+ 3.0) and peripheral arterial disease (LR+ 2.7) were the most predictive factors.
Conclusions:
No clinical findings reliably ruled in 30-day MACE, whereas episodic chest pain lasting seconds and pain lasting more than 24 h markedly decreased the risk of 30-day MACE. Consequently, these two findings can be adjuncts in ruling out 30-day MACE.
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