This Article  • Full text  • PDF  • Send to a friend  • Save in My Folder  • Save to citation manager  • Permissions  Citing Articles  • Citation map  • Citing articles on HighWire  • Citing articles on Web of Science (59)  • Contact me when this article is cited  Related Content  • Related letter  • Similar articles in JAMA  Topic Collections  • Cardiovascular System  • The Rational Clinical Examination  • Cardiovascular Disease/ Myocardial Infarction  • Cardiac Diagnostic Tests  • Alert me on articles by topic  Social Bookmarking   What's this?

Akbar A. Panju, MBChB, FRCPC; Brenda R. Hemmelgarn, PhD, MD; Gordon H. Guyatt, MD, MSc, FRCPC; David L. Simel, MD, MHS

JAMA. 1998;280:1256-1263.

When faced with a patient with acute chest pain, clinicians must distinguish myocardial infarction (MI) from all other causes of acute chest pain. If MI is suspected, current therapeutic practice includes deciding whether to administer thrombolysis or primary percutaneous transluminal coronary angioplasty and whether to admit patients to a coronary care unit. The former decision is based on electrocardiographic (ECG) changes, including ST-segment elevation or left bundle-branch block, the latter on the likelihood of the patient's having unstable high-risk ischemia or MI without ECG changes. Despite advances in investigative modalities, a focused history and physical examination followed by an ECG remain the key tools for the diagnosis of MI. The most powerful features that increase the probability of MI, and their associated likelihood ratios (LRs), are new ST-segment elevation (LR range, 5.7-53.9); new Q wave (LR range, 5.3-24.8); chest pain radiating to both the left and right arm simultaneously (LR, 7.1); presence of a third heart sound (LR, 3.2); and hypotension (LR, 3.1). The most powerful features that decrease the probability of MI are a normal ECG result (LR range, 0.1-0.3), pleuritic chest pain (LR, 0.2), chest pain reproduced by palpation (LR range, 0.2-0.4), sharp or stabbing chest pain (LR, 0.3), and positional chest pain (LR, 0.3). Computer-derived algorithms that depend on clinical examination and ECG findings might improve the classification of patients according to the probability that an MI is causing their chest pain.

From the Departments of Medicine (Drs Panju and Guyatt), Clinical Epidemiology and Biostatistics (Dr Guyatt), and McMaster Medical Programme (Dr Hemmelgarn), McMaster University, Hamilton, Ontario; and the Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Duke University Medical Center, Durham, NC (Dr Simel). Dr Hemmelgarn is currently a resident in internal medicine at the University of Calgary, Alberta.

CiteULike    Connotea    Del.icio.us    Digg    Reddit    Technorati    Twitter     What's this?

RELATED LETTER

Diagnosing Myocardial Infarction: Should Patients Carry a Copy of Their ECG?
Neil L. Kao, Akbar A. Panju, and Brenda R. Hemmelgarn
JAMA. 1999;281(8):705.
EXTRACT | FULL TEXT  

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Getting a better grip on research: the comfort of opinion
Maskrey et al.
InnovAiT 2009;2:679-686.
ABSTRACT | FULL TEXT  

On the philosophy of diagnosis: is doing more good than harm better than "primum non nocere"?
Body and Foex
Emerg. Med. J. 2009;26:238-240.
ABSTRACT | FULL TEXT  

Can a modified thrombolysis in myocardial infarction risk score outperform the original for risk stratifying emergency department patients with chest pain?
Body et al.
Emerg. Med. J. 2009;26:95-99.
ABSTRACT | FULL TEXT  

How should diagnostic tests be evaluated in glaucoma?
Medeiros
Br J Ophthalmol 2007;91:273-274.
FULL TEXT  

Missed opportunities in the primary care management of early acute ischemic heart disease.
Sequist et al.
Arch Intern Med 2006;166:2237-2243.
ABSTRACT | FULL TEXT  

Biomarkers of Cardiovascular Disease: Molecular Basis and Practical Considerations
Vasan
Circulation 2006;113:2335-2362.
FULL TEXT  

Identification of patients with evolving coronary syndromes by using statistical models with data from the time of presentation
Kennedy and Harrison
Heart 2006;92:183-189.
ABSTRACT | FULL TEXT  

Part 5: Acute Coronary Syndromes
Circulation 2005;112:III-55-III-72.
FULL TEXT  

Value and Limitations of Chest Pain History in the Evaluation of Patients With Suspected Acute Coronary Syndromes
Swap and Nagurney
JAMA 2005;294:2623-2629.
ABSTRACT | FULL TEXT  

Does This Dyspneic Patient in the Emergency Department Have Congestive Heart Failure?
Wang et al.
JAMA 2005;294:1944-1956.
ABSTRACT | FULL TEXT  

The ABC of community emergency care: 3 Chest pain
Laird et al.
Emerg. Med. J. 2004;21:226-232.
FULL TEXT  

60-Year-Old Man With Chest Pain
Gami and Jaffe
Mayo Clin Proc. 2004;79:399-402.
 

Randomised controlled trial and economic evaluation of a chest pain observation unit compared with routine care
Goodacre et al.
BMJ 2004;328:254.
ABSTRACT | FULL TEXT  

Triage of Patients with Acute Chest Pain and Possible Cardiac Ischemia: The Elusive Search for Diagnostic Perfection
Goldman and Kirtane
ANN INTERN MED 2003;139:987-995.
ABSTRACT | FULL TEXT  

Clinical predictors of acute coronary syndromes in patients with undifferentiated chest pain
Goodacre et al.
QJM 2003;96:893-898.
ABSTRACT | FULL TEXT  

Cost effectiveness of diagnostic strategies for patients with acute, undifferentiated chest pain
Goodacre and Calvert
Emerg. Med. J. 2003;20:429-433.
ABSTRACT | FULL TEXT  

Does This Patient Have Acute Cholecystitis?
Trowbridge et al.
JAMA 2003;289:80-86.
ABSTRACT | FULL TEXT  

Chest pain units
Clancy
BMJ 2002;325:116-117.
FULL TEXT  

Impact of a Clinical Decision Rule on Hospital Triage of Patients With Suspected Acute Cardiac Ischemia in the Emergency Department
Reilly et al.
JAMA 2002;288:342-350.
ABSTRACT | FULL TEXT  

A prospective, observational study of a chest pain observation unit in a British hospital
Goodacre et al.
Emerg. Med. J. 2002;19:117-121.
ABSTRACT | FULL TEXT  

Is a chest pain observation unit likely to be cost saving in a British hospital?
Goodacre et al.
Emerg. Med. J. 2001;18:11-14.
ABSTRACT | FULL TEXT  

Risk stratification in unstable angina: the role of clinical prediction models
Katz
J Am Coll Cardiol 2000;36:1809-1811.
FULL TEXT  

The Diagnostic Value of Historical Features in Primary Headache Syndromes: A Comprehensive Review
Smetana
Arch Intern Med 2000;160:2729-2737.
ABSTRACT | FULL TEXT  

Users' Guides to the Medical Literature: XXIV. How to Use an Article on the Clinical Manifestations of Disease
Richardson et al.
JAMA 2000;284:869-875.
ABSTRACT | FULL TEXT  

Evaluation of the Patient with Acute Chest Pain
Lee and Goldman
NEJM 2000;342:1187-1195.
FULL TEXT  

Diagnosing Myocardial Infarction: Should Patients Carry a Copy of Their ECG?
Kao et al.
JAMA 1999;281:705-705.
FULL TEXT