Reviews
Bedside diagnosis of coronary artery disease: A systematic review

https://doi.org/10.1016/j.amjmed.2004.03.021Get rights and content

Purpose

To assess the accuracy of bedside findings for diagnosing coronary artery disease and acute myocardial infarction.

Methods

A MEDLINE search was performed to retrieve articles published from January 1966 to January 2003 that were relevant to the bedside diagnosis of coronary disease in adults.

Results

In patients with stable, intermittent chest pain, the most useful bedside predictors for a diagnosis of coronary disease were found to be the presence of typical angina (likelihood ratio [LR] = 5.8; 95% confidence interval [CI]: 4.2 to 7.8), serum cholesterol level >300 mg/dL (LR = 4.0; 95% CI: 2.5 to 6.3), history of prior myocardial infarction (LR = 3.8; 95% CI: 2.1 to 6.8), and age >70 years (LR = 2.6; 95% CI: 1.8 to 4.0). Nonanginal chest pain (LR = 0.1; 95% CI: 0.1 to 0.2), pain duration >30 minutes (LR = 0.1; 95% CI: 0.0 to 0.9), and intermittent dysphagia (LR = 0.2; 95% CI: 0.1 to 0.8) argued against a diagnosis of coronary disease. In patients with acute chest pain, the most important bedside predictors for a diagnosis of myocardial infarction were new ST elevation (LR = 22; 95% CI: 16 to 30), new Q waves (LR = 22; 95% CI: 7.6 to 62), and new ST depression (LR = 4.5; 95% CI: 3.6 to 5.6). A normal electrocardiogram (LR = 0.2; 95% CI: 0.1 to 0.3), chest wall tenderness (LR = 0.3; 95% CI: 0.2 to 0.4), and pain that was pleuritic (LR = 0.2; 95% CI: 0.2 to 0.3), sharp (LR = 0.3; 95% CI: 0.2 to 0.5), or positional (LR = 0.3; 95% CI: 0.2 to 0.5) argued against the diagnosis of myocardial infarction.

Conclusion

The accuracy of bedside predictors depends on the clinical setting. In the evaluation of stable, intermittent chest pain, a patient's description of pain was found to be the most important predictor of underlying coronary disease. In the evaluation of acute chest pain, the electrocardiogram was the most useful bedside predictor for a diagnosis of myocardial infarction. Aside from the extremes in cholesterol values, the analysis of traditional risk factors changed the probability of coronary disease or myocardial infarction very little or not at all.

Section snippets

Methods

Using MEDLINE (January 1966 to January 2003), one author (AAC) performed the following search strategy, limited to English-language publications and human subjects, to retrieve all relevant publications on the bedside diagnosis of coronary artery disease in adults. The following Medical Subject Heading terms were combined with the terms coronary disease/diagnosis and myocardial infarction/diagnosis: chest pain/diagnosis, electrocardiography, risk factors, physical examination, and medical

Coronary artery disease

The overwhelming majority of patients in these studies presented to outpatient clinics with stable, intermittent chest pain and were subsequently referred for coronary angiography. Most studies (14, 17, 19, 22, 33, 37, 38) excluded patients with known valvular heart disease or nonischemic cardiomyopathy. Some studies used >50% stenosis of any epicardial vessel as the diagnostic standard (13, 14, 15, 16, 17, 19, 22, 23, 24, 25, 26, 27, 28, 29, 37, 38, 39, 40, 41, 42, 43, 44, 45), whereas others

Discussion

In 1768, Heberden described typical angina as a “most disagreeable sensation in the breast” that seizes patients “while they are walking” yet vanishes “the moment they stand still” (1). Modern definitions of typical angina (Table 1) retain Heberden's triad of essential ingredients—substernal discomfort, aggravation by exertion, and relief with rest—adding only that typical angina requires relief within 10 minutes of rest or within 10 minutes of taking nitroglycerin. Our review shows that this

References (73)

  • N. Hoogerbrugge et al.

    Corneal arcusindicator for severity of coronary atherosclerosis?

    Neth J Med

    (1999)
  • C.M. Papamichael et al.

    Ankle-brachial index as a predictor of the extent of coronary atherosclerosis and cardiovascular events in patients with coronary artery disease

    Am J Cardiol

    (2000)
  • B. Reilly et al.

    Performance and potential impact of a chest pain prediction rule in a large public hospital

    Am J Med

    (1999)
  • L. Durairaj et al.

    Emergency department admissions to inpatient cardiac telemetry bedsa prospective cohort study of risk stratifications and outcomes

    Am J Med

    (2001)
  • D.B. Pryor et al.

    Estimating the likelihood of severe coronary artery disease

    Am J Med

    (1991)
  • R. DerSimonian et al.

    Meta-analysis in clinical trials

    Control Clin Trials

    (1986)
  • C.C. Welch et al.

    Coronary arteriographic findings in 1,000 women under age 50

    Am J Cardiol

    (1975)
  • O. Gurevitz et al.

    Clinical profile and long-term prognosis of women <= 50 years of age referred for coronary angiography for evaluation of chest pain

    Am J Cardiol

    (2000)
  • C.P. Miranda et al.

    Correlation between resting ST segment depression, exercise testing, coronary angiography, and long-term prognosis

    Am Heart J

    (1991)
  • C.G. Solomon et al.

    Comparison of clinical presentation of acute myocardial infarction in patients older than 65 years of age to younger patientsthe multicenter chest pain study experience

    Am J Cardiol

    (1989)
  • W.G. Baxt et al.

    A neural computational aid to the diagnosis of acute myocardial infarction

    Ann Emerg Med

    (2002:)
  • J. Herlitz et al.

    Early identification of patients with an acute coronary syndrome as assessed by dispatchers and the ambulance crew

    Am J Emerg Med

    (2002)
  • J. Herlitz et al.

    A description of the characteristics and outcome of patients hospitalized for acute chest pain in relation to whether they were admitted to the coronary care unit or not in the thrombolytic era

    Int J Cardiol

    (2002)
  • F. Lopez-Jimenez et al.

    Effect of diabetes mellitus on the presentation and triage of patients with acute chest pain without known coronary artery disease

    Am J Med

    (1998)
  • B.W. Karlson et al.

    Early prediction of acute myocardial infarction from clinical history, examination and electrocardiogram in the emergency room

    Am J Cardiol

    (1991)
  • G.W. Rouan et al.

    Clinical characteristics and outcome of acute myocardial infarction in patients with initially normal or nonspecific electrocardiograms

    Am J Cardiol

    (1989)
  • F.M. Fesmire et al.

    Usefulness of automated serial 12-lead ECG monitoring during the initial emergency department evaluation of patients with chest pain

    Ann Emerg Med

    (1998)
  • K. Wrenn et al.

    Using the “GI cocktail”a descriptive study

    Ann Emerg Med

    (1995)
  • G.R. Schwartz

    Xylocaine viscous as an aid in the differential diagnosis of chest pain

    JACEP

    (1976)
  • R.L. Jayes et al.

    Do patients' coronary risk factor reports predict acute cardiac ischemia in the emergency department? A multicenter study

    J Clin Epidemiol

    (1992)
  • E.J. Boyko et al.

    The use of risk factors in medical diagnosisopportunities and cautions

    J Clin Epidemiol

    (1990)
  • M.W. Dickinson

    The “GI cocktail” in the evaluation of chest pain in the emergency department

    J Emerg Med

    (1996)
  • L.R. Welling et al.

    The emergency department treatment of dyspepsia with antacids and oral lidocaine

    Ann Emerg Med

    (1990)
  • National Vital Statistics Report....
  • T.H. Lee et al.

    Acute chest pain in the emergency roomidentification and examination of low-risk patients

    Arch Intern Med

    (1985)
  • L. Goldman et al.

    A computer-derived protocol to aid in the diagnosis of emergency room patients with acute chest pain

    N Engl J Med

    (1982)
  • Cited by (95)

    • Hematological Biomarkers, Mortality, Transfusion and Acute Heart Disease

      2021, American Journal of the Medical Sciences
      Citation Excerpt :

      Cardiovascular disease (CVD) signals an unfavorable outcome with an increased risk of recurrent events, morbidity and mortality.1,2 Although clinical evaluation is the major component of patient management, this assessment has several limitations.3,4,5,6 Thus, additional tools have been investigated to enhance the clinical assessment of patients at risk, one of them being hematological markers.7,8,9,10

    • The association of chest pain duration and other historical features with major adverse cardiac events

      2020, American Journal of Emergency Medicine
      Citation Excerpt :

      Prior studies support these findings [4,20,21]. Additionally, our finding that chest pain described as a pressure is a weak positive predictor of acute MI is consistent with prior data [18,24]. Next, our finding that chest pain severity does not help predict acute MI is also consistent with prior literature [21,25], and is consistent with an emerging theme in the literature suggesting that self-reported pain scores may not have predictive clinical utility in general [26].

    • High-Risk Chief Complaints I: Chest Pain—The Big Three (an Update)

      2020, Emergency Medicine Clinics of North America
    View all citing articles on Scopus
    View full text