Mostly Dead Is Slightly Alive - H&P in Chest Pain

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History and exam features must be used as part of a risk stratification strategy that includes ECG and troponin.  Be especially wary if the history includes: diaphoresis, reported vomiting, radiation of pain to both arms or the right arm, or pain with exertion.

Why does this matter?
Being falsely reassured because a patient lacks "typical" features for angina will cause you to miss patients with ACS.  Knowing which features in the history should heighten concern is also important.

Is H&P for chest pain mostly dead? (Princess Bride reference in honor of coauthor Amal Mattu)
It may be mostly dead, but like Princess Bride, "mostly dead is slightly alive."  A few variables were associated with increased risk of ACS and included: diaphoresis (especially observed in the ED) or reported vomiting; radiation of pain to both arms or the right arm; pain with exertion.  Some were associated with decreased risk: reproducible chest wall tenderness; pleuritic, sharp, or positional pain.  None of these features has the ability to independently discriminate, and therefore must be used in conjunction with ECG and troponin.  "Atypical" features don't rule out ACS; "typical" features don't rule it in. To see the artful use of clinical and lab variables as a risk stratification strategy, see the other article by Rick Body this month, T-MACS.  Other examples would be EDACS and the HEART score.

Utility of the History and Physical Examination in the Detection of Acute Coronary Syndromes in Emergency Department Patients.  West J Emerg Med. 2017 Jun;18(4):752-760. doi: 10.5811/westjem.2017.3.32666. Epub 2017 May 3.

Peer reviewed by Thomas Davis, MD.

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