Tips and tools to help refine your approach to chest pain
Which history and exam findings have high predictive value for different causes of chest pain? Which decision tool can best assess for CAD in your practice setting?
PRACTICE RECOMMENDATIONS
› Use the highly sensitive Marburg Heart Score to rule out coronary artery disease as a cause of chest pain in the ambulatory care setting. B
› Consider a prior normal stress test result nonpredictive of outcome in a patient presenting with chest pain. Patients with such a history of testing have a risk of a 30-day adverse cardiac event that is similar to the risk seen in patients who have never had a stress test. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
a Risk factors include hypertension, hypercholesterolemia, diabetes, obesity (body mass index > 30), smoking (current, or smoking cessation for ≤ 3 mo), and family history of CAD (ie, parent or sibling affected before 65 years of age). Atherosclerotic disease includes history of AMI, percutaneous coronary intervention or coronary artery bypass grafting, stroke, or peripheral artery disease.
The HEART score is calculated based on 5 components:
- History of chest pain (slightly [0], moderately [+1], or highly [+2]) suspicious for ACS)
- EKG (normal [0], nonspecific ST changes [+1], significant ST deviations [+2])
- Age (< 45 y [0], 45-64 y [+1], ≥ 65 y [+2])
- Risk factors (none [0], 1 or 2 [+1], ≥ 3 or a history of atherosclerotic disease [+2]) a
- Initial troponin assay, standard sensitivity (≤ normal [0], 1-3× normal [+1], > 3× normal [+2]).
For patients with a HEART score of 0-3 (ie, at low risk), the pooled positive predictive value of a MACE was determined to be 0.19 (95% CI, 0.14-0.24), and the negative predictive value was 0.99 (95% CI, 0.98-0.99)—making it an effective tool to rule out a MACE over the short term26 (TABLE 34,26-28).
Because the HEART Score was published in 2008, multiple systematic reviews and meta-analyses have compared it to the TIMI (Thrombolysis in Myocardial Infarction) and GRACE (Global Registry of Acute Coronary Events) scores for predicting short-term (30-day to 6-week) MACE in ED patients.27,28,33,34 These studies have all shown that the HEART score is relatively superior to the TIMI and GRACE tools.
Characteristics of these tools are summarized in TABLE 3.4,26-28
Diamond Forrester classification (in ED and outpatient settings). This tool uses 3 criteria—substernal chest pain, pain that increases upon exertion or with stress, and pain relieved by nitroglycerin or rest—to classify chest pain as typical angina (all 3 criteria), atypical angina (2 criteria), or noncardiac chest pain (0 criteria or 1 criterion).24 Pretest probability (ie, the likelihood of an outcome before noninvasive testing) of the pain being due to CAD can then be determined from the type of chest pain and the patient’s gender and age19 (TABLE 419). Recent studies have found that the Diamond Forrester criteria might overestimate the probability of CAD.35
Continue to: Noninvasive imaging-based diagnostic methods
