History and Physical for ACS Rule-Out?

January 20, 2020

Written by Clay Smith and Rick Ramirez

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Chest pain lasting either seconds or over 24 hours decreased risk for 30-day major adverse coronary events (MACE).

Why does this matter?
The history of the type of chest pain, other cardiac risk factors, and the physical exam (rales, pain with palpation, etc) are used in ACS scoring systems, such as HEART, GRACE, EDACS, Vancouver, and more. The authors were concerned that results in prior studies were not consistent. They wanted to rigorously and prospectively assess the accuracy of elements of the history and physical exam on predicting 30-day MACE.

Doc, I’ve had some chest pain the last couple years I’m worried about…
This was a prospective study with 1,167 patients in the ED with non-traumatic chest pain. It was a secondary analysis of previously collected data. They found no elements of the history that were powerful enough discriminators to rule in ACS. However, pain radiating to both arms (+LR 2.7), history of diabetes (+LR 3.0), and history of peripheral arterial disease (+LR 2.7) were mildly predictive. Also, related to history alone, chest pain lasting seconds (+LR 0.0), >24 hours (+LR 0.1), or right-sided pain (+LR 0.2) lowered risk. Associated symptoms such as diaphoresis, dyspnea, or nausea had no impact (+LR 1.0 or 1.1 with non-significant 95%CIs). On exam, presence of rales (+LR 3.0) increased risk mildly and pain with palpation (+LR 0.3) decreased risk. This was performed at a single ED in Sweden, which impacts generalizability. Also, though the study enrolled a large number of total patients, for each variable the numbers were often small, resulting in wide 95% confidence intervals for some of them. What’s new and significant is that pain lasting seconds or >24 hours may need to be considered as negative predictors in future ACS prediction tools.

A similar article was also published this same month in AJEM. It was a prospective, single-center, observational study of 1000 patents that found chest pain lasting ≤1 min had +LR 0.95 (0.24–3.80). Continuous pain ≥24 hours had a reduced LR for AMI [+LR 0.15 (0.04–0.58)] as did sharp or stabbing pain [+LR 0.44 (0.21–0.93)]. Again, pain radiating to the right shoulder and arm or both shoulders and arms was mildly predictive of AMI and MACE as was a pressure sensation as opposed to sharp.

Sources

• Diagnostic Accuracy of History and Physical Examination for Predicting Major Adverse Cardiac Events Within 30 Days in Patients With Acute Chest Pain.  J Emerg Med. 2019 Nov 25. pii: S0736-4679(19)30828-5. doi: 10.1016/j.jemermed.2019.09.044. [Epub ahead of print]
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• The association of chest pain duration and other historical features with major adverse cardiac events. Am J Emerg Med. 2019 Nov 20. pii: S0735-6757(19)30758-2. doi: 10.1016/j.ajem.2019.11.020. [Epub ahead of print]
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