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.
Other historical features or physical exam findings correlate with aortic dissection, pneumonia, and psychiatric causes of chest pain (TABLE 25-9).
Useful EKG findings
Among patients in whom ACS or PE is suspected, 12-lead electrocardiography (EKG) should be performed.
AMI. EKG findings most predictive of AMI are new ST-segment elevation or depression > 1 mm (LR = 6-54), new left bundle branch block (LR = 6.3), Q wave (positive LR = 3.9), and prominent, wide-based (hyperacute) T wave (LR = 3.1).10
ACS. Useful EKG findings to predict ACS are ST-segment depression (LR = 5.3 [95% CI, 2.1-8.6]) and any evidence of ischemia, defined as ST-segment depression, T-wave inversion, or Q wave (LR = 3.6 [95% CI, 1.6-5.7]).10
PE. The most common abnormal finding on EKG in the setting of PE is sinus tachycardia.
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