Signs and Evidence

Making clinical sense of scientific data

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Acute coronary syndrome

Calculated pretest-probability: 3.74 %
Relevant inclusion criteria: Primary care, all chest pain Calculate probabilities!

Clinical signs

Exertional Pain
 Positive likelihood ratio
2.35 ( Goodacre S et al. )
(average) 2.35
Negative likelihood ratio
0.76 ( Goodacre S et al. )
(average) 0.76
Crackles
 Positive likelihood ratio
2.08 ( Mant J et al. )
(average) 2.08
Negative likelihood ratio
0.76 ( Mant J et al. )
(average) 0.76
Nausea
 Positive likelihood ratio
1.88 ( Mant J et al. )
(average) 1.88
Negative likelihood ratio
0.77 ( Mant J et al. )
(average) 0.77
Polakysuria
 Positive likelihood ratio
1.80 ( Rudi Bruyninckx et al. )
(average) 1.80
Negative likelihood ratio
0.60 ( Rudi Bruyninckx et al. )
(average) 0.6
Sweating
 Positive likelihood ratio
1.34 ( Rudi Bruyninckx et al. )
2.06 ( Mant J et al. )
(average) 1.70
Negative likelihood ratio
0.85 ( Rudi Bruyninckx et al. )
0.65 ( Mant J et al. )
(average) 0.75
Vomiting
 Positive likelihood ratio
1.32 ( Rudi Bruyninckx et al. )
(average) 1.32
Negative likelihood ratio
0.93 ( Rudi Bruyninckx et al. )
(average) 0.93
Pain in left arm
 Positive likelihood ratio
1.30 ( Rudi Bruyninckx et al. )
(average) 1.30
Negative likelihood ratio
0.88 ( Rudi Bruyninckx et al. )
(average) 0.88
Epigastric pain
 Positive likelihood ratio
1.05 ( Rudi Bruyninckx et al. )
(average) 1.05
Negative likelihood ratio
0.98 ( Rudi Bruyninckx et al. )
(average) 0.98
Chest-wall tenderness
 Positive likelihood ratio
0.17 ( Rudi Bruyninckx et al. )
0.30 ( Goodacre S et al. )
0.23 ( Mant J et al. )
(average) 0.23
Negative likelihood ratio
1.41 ( Rudi Bruyninckx et al. )
1.27 ( Goodacre S et al. )
1.18 ( Mant J et al. )
(average) 1.29

Further signs

Troponin I > 1,5 ng/mL after 6 hours
 Positive likelihood ratio
15.33 ( Zimmerman J et al. )
(average) 15.33
Negative likelihood ratio
0.09 ( Zimmerman J et al. )
(average) 0.09
ST-elevation
 Positive likelihood ratio
13.10 ( Mant J et al. )
(average) 13.10
Negative likelihood ratio
0.47 ( Mant J et al. )
(average) 0.47
CK-MB subforms ratio > 1,6 after 6 hours
 Positive likelihood ratio
8.27 ( Zimmerman J et al. )
(average) 8.27
Negative likelihood ratio
0.10 ( Zimmerman J et al. )
(average) 0.1
Q-waves
 Positive likelihood ratio
5.01 ( Mant J et al. )
(average) 5.01
Negative likelihood ratio
0.45 ( Mant J et al. )
(average) 0.45
ST-depression
 Positive likelihood ratio
5.00 ( Fanaroff AC et al. )
3.13 ( Mant J et al. )
(average) 4.07
Negative likelihood ratio
0.80 ( Fanaroff AC et al. )
0.60 ( Mant J et al. )
(average) 0.7
Normal ECG
 Positive likelihood ratio
0.14 ( Mant J et al. )
(average) 0.14
Negative likelihood ratio
1.58 ( Mant J et al. )
(average) 1.58

Sources used:

1.Rudi Bruyninckx et al. Signs and symptoms in diagnosing acute myocardial infarction and acute coronary syndrome: a diagnostic meta-analysis. Br J Gen Pract 2008; 58 (547): e1-e8.
2.Goodacre S et al. How Useful Are Clinical Features in the Diagnosis of Acute, Undifferentiated Chest Pain? Academic emergency medicine 2002; 9:203–208
3.Mant J et al. Systematic review and modelling of the investigation of acute and chronic chest pain presenting in primary care. Health Technology Assessment Volume: 8, Issue: 2, Published in February 2004
4.Zimmerman J et al. Diagnostic marker cooperative study for the diagnosis of myocardial infarction. Circulation. 1999 Apr 6;99(13):1671-7
5.Fanaroff AC et al. Does This Patient With Chest Pain Have Acute Coronary Syndrome?: The Rational Clinical Examination Systematic Review. JAMA. 2015 Nov 10;314(18):1955-65
6.Cervellin G et al. Epidemiology and outcomes of acute abdominal pain in a large urban Emergency Department: retrospective analysis of 5,340 cases. Ann Transl Med. 2016 Oct; 4(19): 362