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Mokhtari et al. SpringerPlus(2015) 4:219DOI 10.1186/s40064-015-0992-9

a SpringerOpen Journal

RESEARCH Open Access

Diagnostic va!"s o# ch"st $ain histor%&'()& tro$onin an* cinica g"stat in$ati"nts +ith ch"st $ain an* $ot"ntiaac!t" coronar% s%n*ro," ass"ss"* in th"","rg"nc% *"$art,"ntArash Mokhtari

1,3*, Eric Dryver

2,3, Martin Söderholm

2and Ulf Ekelund

2,3

Abstract

n the assessment of chest !ain !atients "ith sus!ected acute coronary syndrome #A$S% in the emer&encyde!artment #ED%, !hysicians rely on &lo'al dia&nostic im!ressions #&estalt%( )he aim of this study "as to determinethe dia&nostic value of the ED !hysicians overall assessment of A$S likelihood, and the values of the maindia&nostic modalities underlyin& this assessment, namely the chest !ain history, the E$ and the initial tro!oninresult( 1,1+1 consecutive ED chest !ain !atients "ere !ros!ectively included( )he ED !hysicians inter!retation ofthe chest !ain history, the E$, and the &lo'al likelihood of A$S "ere recorded on s!ecial forms( )he dischar&edia&noses "ere retrieved from the medical records( A chart revie" "as carried out to determine "hether !atients"ith a nonA$S dia&nosis at the inde- visit had A$S or suffered cardiac death "ithin 3. days( )he &estalt "as 'etterthan its com!onents 'oth at rulin& in #Obvious ACS, /0 2% and at rulin& out #No Suspicion of ACS, /0.(.1% A$S(n the Strong suspicion of ACS &rou!, . of the !atients did not have A$S( A !ositive )n) #/0 24(% and an

ischemic E$ #/0 5(3% "ere stron& !redictors of A$S and seemed su!erior to !ain history for rulin& in A$S( n !atients"ith a normal )n) and nonischemic E$, chest !ain history ty!ical of AM "as not a si&nificant !redictor of AM#/0 1(% "hile !ain history ty!ical of unsta'le an&ina #UA% "as a moderate !redictor of UA #/0 4(6%($linical &estalt "as 'etter than its com!onents 'oth at rulin& in and at rulin& out A$S, 'ut overestimated thelikelihood of A$S "hen cases "ere assessed as stron& sus!icion of A$S( Amon& the com!onents of the &estalt,)n) and E$ "ere su!erior to the chest !ain history for rulin& in A$S, "hile !ain history "as su!erior for rulin&out A$S(

"%+or*s: Acute coronary syndrome7 $hest !ain7 E$7 Dia&nosis7 estalt7 8ro'a'ility

Background

Non-traumatic chest pain is a common presenting com-

plaint among patients seeking care in the Emergency

Department (ED). The management of these patients

often hinges upon the perceived likelihood that an acute

coronary syndrome (AC) accounts for the patient.s

chest pain. A su!stantial proportion of patients "ith

chest pain are admitted for inpatient care in order to

rule-out AC# and many undergo stress testing# of "hich

only a small proportion are a!normal and lead to a

change in management ($enumetsa et al. %&'%). Theseadmissions and investigations in patients "ithout AC

cause a su!stantial health care !urden (oodacre et al.

%&&). At the same time# %-*+ of patients "ith AC

are erroneously discharged from the ED (,ee et al.

'/0 $ope et al. %&&&). These patients have a higher

mortality than patients "ith AC "ho are admitted#

further em-

phasi1ing the need for an improved assessment of the* $orres!ondence9 arash:-(mokhtari;med(lu(se1De!artment of nternal Medicine, Skull list of author information is availa'le at the end of the article

likelihood of AC in the emergency department (,ee

et al. '/0 $ope et al. %&&&).

The main tools used to determine the likelihood of

AC in the ED are the chest pain history# the EC

and

mailto:[email protected]:[email protected]:[email protected]

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? 2.1+ Mokhtari et al(7 licensee S!rin&er( )his is an @!en Access article distri'uted under the terms of the $reative $ommonsAttri'ution /icense #htt!9creativecommons(or&licenses'y4(.%, "hich !ermits unrestricted use, distri'ution, and re!roductionin any medium, !rovided the ori&inal "ork is !ro!erly credited(

http://creativecommons.org/licenses/by/4.0http://creativecommons.org/licenses/by/4.0

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Mokhtari et al. SpringerPlus ag" 2 o#

!lood markers of myocardial in2ury such as troponins.

The predictive values for AC of these diagnostic

methods have !een e3tensively analy1ed (Chun and

4cee %&&*0 $an2u et al. '0 "ap and Nagurney

%&&0 ,ee et al. ')# !ut the studies have mostly

focused on single items (e.g. radiation to the arms) and

on diagnosing acute myocardial infarction (A45) and

not AC. ingle items are insufficient predictors of

AC for the purpose of ED decision-making ("ap and

Nagurney %&&)# and a num!er of clinical prediction rules

com!in- ing items have therefore !een developed

(Christenson et al. %&&60 7esmire et al. %&'%0 8ess et

al. %&'%0 i3 et al. %&&). 8o"ever# the value of these

prediction rules in ED routine care has not yet !een

esta!lished (8ess et al. %&&0 4anini et al. %&&0 teurer

et al. %&'&). 4ost clinicians instead rely on a glo!al#

su!2ective patient assessment kno"n as -gestalt..

tudies have demon- strated that the clinical gestaltfor pulmonary em!olism performs at least as "ell as

clinical prediction rules (Chunilal et al. %&&90 :unyon et

al. %&&0 $enalo1a et al. %&'9). Also# the clinical gestalt

for acute cholecystitis has a high predictive accuracy

even in the a!sence of indi- vidual findings "ith high

predictive po"er (Tro"!ridge et al. %&&9). The

diagnostic accuracy of the clinical gestalt for AC is

unclear.

;no"ledge of the diagnostic accuracy of the gestalt

for AC may help ED clinicians to make !etter deci-

sions "hen managing patients "ith chest pain. The

aim of this study "as to determine the diagnostic

value of the ED physician.s overall clinical assessment

of AC likelihood# and the values of the main diag-

nostic modalities underlying this assessment# namely

the chest pain history# the EC and the initial tropo-

nin result.

Methods

t!*% sit"

The k) are availa!le %* hours aday. :oughly 6#&&& patients are assessed every year

in the ED# of "hich a!out #&& present "ith non-

traumatic chest pain. There is no dedicated chest pain

o!servation unit. $atients "ith T-elevation myocardial

infarction (TE45) "ho are identified via am!ulance

ECs as a rule !ypass the ED and are taken directly

to the angiography suite.

ati"nt $o$!ation

All patients aged over ' years "ho presented "ith non-

traumatic chest pain to the ,und ED during ?une '%th -

@cto!er th %&& "ere prospectively identified and

enrolled in the study. $atients "ere e3cluded from the

analysis if the history "as unrelia!le due to e.g.

alcohol into3ication or dementia# if they "ere transferred

to an- other hospital# if they refused admission for

inpatient evaluation# or if data "ere missing.

o!tin" cinica ass"ss,"nt

All included patients "ere initially assessed !y a triage

team that measured vital signs# recorded an EC and

took routine !lood tests including a troponin T (TnT).

The patients "ere then assessed !y a resident or a

specialist in internal andor emergency medicine.

This physician took a history# performed a physical

e3am# and if necessary# revie"ed the case "ith a se-

nior colleague.

Data co"ction

After the patient encounter# the physician or one of

the authors (4) recorded the physician.s assessment of

the patient on a specific study form (see Additional

file '). The assessments "ere all made at the same time.

7irst# the physician categori1ed the chest pain history

as typical of AMI, typical of Unstable Angina (UA), non-

specific for ACS # or not suspicious of ACS . The form

specified that central# pressure-type pain lasting over

' minutes "ith or "ithout radiation to the arm or

shoulder is considered typical for A45. pecifications

for the other categories "ere not provided. Ne3t# the

physician noted the presence or a!sence of the follo"ing

EC changesB a) T-elevation or depression 6 ' mm in atleast t"o anatomically contiguous leads0 !) left !undle

!ranch !lock (,>>>)0 c) pathological -"aves in at

least t"o anatomically contiguous leads0 d) T-"ave

inver- sions in at least t"o anatomically contiguous

leads. 5n the present study# a non-ischemic EC "as

defined as an EC lacking all of the findings a!ove.

,ast# physicians recorded their composite assessment of

the likelihood of AC !ased on the chest pain history#

EC and the first TnT value# "hich in principle "as

al- "ays availa!le at the time of assessment. 5n order to

limit heterogeneity of the assessments# physicians had to

choose among four AC likelihood levels# "ith

suggested definitions provided on the data formB

Obvious ACS # typical symptoms and T-elevation or

,>>> not previously o!served0 Strong suspicion of

ACS, a) typical symptoms or

!) T-T changes or ,>>> not previously o!served# or

c)acute heart failure or hypotension regardless of EC or

d) ventricular tachycardiafi!rillation or A-!lock 5550 Low

suspicion of ACS, unclear symptoms and history# non-

ischemic EC0 and o suspicion of ACS # a) no

suspicion of ischemic heart disease# or !) sta!le angina

pectoris. The physicians "ere free to disregard these

definitions# !ut the definitions "here non-controversial

and reflected common clinical reasoning at the hospitalduring the study.

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The troponin assay used in this study "as Elecsys tropo-

nin T# "hich has a th percentile cutoff of &.&' μg,# and

"ith &.&9 μg, reported as the lo"est concentration "ith a

coefficient of variation 7 '&+. The first TnT test

result "as retrieved from the electronic patient records#

"ith values 6 &.& μg, !eing considered indicative of

AC.

O!tco," ,"as!r"s

$atients admitted after the ED assessment "ere cared

for !y "ard physicians !linded to the data form. The

discharge diagnosis (5CD '&) "as o!tained from the

discharge summary# "hich "as "ritten !y the

"ard physician and revie"ed for uality and accuracy

!y a specialist in internal medicine andor cardiology. 7or

patients discharged from the ED# the discharge

diagnosis (5CD '&) "as retrieved from the ED patient

record "ritten !y the responsi!le ED physician.$atients "ere considered to have AC if they received

the diagnosis in the k4

$ tatistics v' and 4icrosoft E3cel %&&/. All

included patients gave informed consent in "riting# and

the study "as approved !y the regional ethicscommittee in ,und (DN: %&&69&).

Results

ati"nt charact"ristics

As sho"n in 7igure '# '#%%% patients "ere included in the

study. eventy-one patients "ere e3cluded !ased on

prede- fined criteria# leaving '#'' patients in the final

analysis. The !aseline characteristics of these patients

are listed in Ta!le '. The mean age "as 6' years# %+

had a history of coronary artery disease (CAD)# and '+

had dia!etes. 7ifty- four per cent of the patients "ere

admitted for inpatient care !ut only %9+ of these hadAC. 5n the entire study population# '9+ had a final

diagnosis of AC (/ A45# * =A) during the inde3

visit or "ithin 9& days. 5n the remaining patients# the

most common causes of chest pain "ere unspecified

chest pain# musculoskeletal pain# and sta!le angina.

@ne case of A45 and four cases of =A "ere missed

according to our criteria# implying a 9.*+ miss rate.

Diagnostic $"r#or,anc" o# car*iac risk #actors

As can !e seen in Ta!le %# age G *& years almost e3-

cluded AC (,: &.&%) "hile higher age increased the

AC pro!a!ility only slightly. A previous historyof CAD# peripheral artery disease ($AD)# stroke and

dia- !etes did not alter post-test pro!a!ility of AC.

Figure 1 >lo" dia&ram of enrolled and e-cluded !atients(

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Table 1 Baseline patient characteristics and phsician

assess!entsTable " #iagnostic per$or!ance o$ cardiac risk $actors in

percent %&'( C)* $or ACS +ithin ,- das

$ati"nts % with ACS n = 146 n = 111 !%" !#$ &' 4# (A"

& ik"ihoo* ratio D& $"ri$h"ra art"r% *is"as" D& oronar% art"r% *is"as".

Table , #iagnostic per$or!ance o$ phsician

assess!ents in percent %&'( C)* $or ACS +ithin ,- das

D& $"ri$h"ra art"r% *is"as" D& oronar% art"r% *is"as".& c!t" coronar% s%n*ro," MI& c!t" ,%ocar*iain#arction ;& ;nsta

The diagnostic performances of the assessments are de-

scri!ed in Ta!les 9 and *. Chest pain history 2udged

!y the physician as typical of A45 increased the

pro!a!ility of A45 (,: *.# Ta!le 9). 8o"ever# "hen

e3cluding patients "ith ischemic EC changes and

elevated initial troponins (Ta!le *)# chest pain historydeemed typical of

& c!t" coronar% s%n*ro," & ik"ihoo* ratio >n>& >ro$onin > ;& ;nsta

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Table . #iagnostic per$or!ances o$ chest pain histor in

percent %&'( C)* in patients +ith non/ische!ic EC0 and

nor!al initial troponin T

"nsi tivit% $" ci# ic it % -

Chest pain histor)

)y!ical of A$S 32 #2+E3% 53 #51E5% 1( #1(42(+% .(5 #.(6.(%

)y!ical of AMH 11 #E1% 3 #1E4% 1( #.(3(.% 1(. #.(1(.%

)y!ical of UA@ 4+ #32E+% . #5E2% 4(6 #3(3(6% .( #.(+.(5%

ons!ecific for A$S #3E11% 4 #1E6% .(2 #.(1.(3% 1(+ #1(41(%

**' patients "ith a / o Suspicion of ACS 0 gestalt

had AC "ithin 9& days. 5n accordance "ith the

results !y ;line et al. %&'* (;line and tu!!lefield)#

a / o Suspicion0 gestalt thus seems to rule out AC

in the ED# and to o!viate the need for admission#serial troponins# and stress-testing for the e3clusion

of AC. 4iller et al. found that %.+ of ED patients

assessed as /noncardiac chest pain0 had adverse cardiac

events "ithin 9& days (4iller et al. %&&*). 8o"ever# in

that study TnT "as not measured in all patients and the

gestalt im-ot sus!iciousof A$S

.(3 #.E3% . #+6E3% .(.1 #.(...(13% 1(6 #1(1(5%

pression "as recorded !efore !iomarkers "ere dra"n.

A!out half of their patients "ith adverse cardiac

events& ik"ihoo* ratio & c!t" coronar% s%n*ro," MI& c!t",%ocar*iain#arction ;& ;nsta

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turned out to have elevated troponins meaning they

"ould not have !een classified in the / o Suspicion

of ACS 0 group in our study. A / o Suspicion of ACS 0

gestalt and a non-suspicious chest pain history !oth

almost e3- cluded AC# and one might speculate that the

ED physicians !ased their no suspicion gestalt

primarily on the chest pain history. @ur results thus

suggest that a non- suspicious pain history may in

many cases !e enough to rule out AC in the ED# at

least if the pretest pro!a!ility is lo". @nly &.%+ of

the patients "ith a non-suspicious pain history had

AC "ithin 9& days in our population. 7urther# the

study confirms previous findings that age G *& years

argues strongly against AC (Collin et al. %&''0

4arsan et al. %&&)# "hile older age has limited pre-

dictive value (Chun and 4cee %&&*).

Fe have found four previous pu!lications "ith data on

the diagnostic or prognostic value of the overall clinical

gestalt in patients "ith possi!le AC. 8o"ever# t"o

of the studies "ere from !efore the modern

!iomarker era and focused on A45 only (;arlson et

al. ''0 Tierney et al. '6)# one "as much smaller than the present study and included patients "ithout

chest pain andor TnT tests (Ekelund et al. %&&%)# and

one "as primarily prognostic and included only lo" risk

patients (Chandra et al. %&&). 5n the present study# the

gestalt had largest predictive a!ility "hen cases "ere

assessed as /Obvious ACS 0 or / o suspicion of ACS 0.

5n the strong suspicion group# it ap- peared that the

physicians. gestalt overestimated the likelihood of

AC# since 6&+ of these patients did not have AC.

The value of a high grade of suspicion of AC may thus

!e less than generally !elieved. 5n this conte3t# ;line et

al. %&'* reported that emergency physicians tend to

overestimate the likelihood of AC also in lo" risk

patients (;line and tu!!lefield). 5n the lo" suspicion

gestalt group 6+ of the patients had AC# "hich indicates

that these patients should in general undergo further

evaluation.

5n accordance "ith previous findings# a negative initial

TnT and a non-ischemic EC did not relia!ly rule-out

AC (Chun and 4cee %&&*0 E!ell et al. %&&&0

7esmire et al. '). @n the other hand# TnT and EC

seemed superior to chest pain history for ruling in

AC. @ur findings thus support the practice of admitting all chest

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pain patients "ith ischemic ECs andor elevated TnT for

additional evaluation. 5n patients "ith a non-ischemic

EC and a negative initial TnT# a pain history typical

of A45 "as poorly predictive of A45 (,: '.6). 5n

contrast# pain typical of =A "as still a moderate

predictor of =A (,: *./). The results thus indicate that

patients "ith a pain history typical of =A should

undergo further evaluation# regardless of the EC and

TnT results# "hich is pro!a!ly true even if highly

sensitive troponins are used (>orna et al. %&'*).

i,itations o# th" st!*%

This study "as performed at only one university hospital

and the results are not necessarily generali1a!le to other

hospitals. 8o"ever# the prevalence of AC among

chest pain patients "as '%./+# "hich is compara!le to

that in other studies of unselected ED chest pain patients (8an et al. %&&/0 cheuermeyer et al. %&'%).

The discharge diagnoses "ere those used in routine

clinical care. ince "e aimed to study diagnostic value

in routine care# "e did not assess the diagnoses for

accuracy# and "e have no data on "hat proportion

"ere !ased on o!2ective testing# e.g. stress tests or

coronary angiography. 8o"ever# at our institution "hich

is the academic cardiac center for the entire region#

most patients are evaluated "ith stress testing and

virtually all patients "ith AC undergo coronary

angiography. All discharge diagnoses "ere revie"ed for

uality and accuracy !y the attending specialist

physician (most often cardiologist# in a fe" cases internal

medicine specialist). 5n addition# the patients "ere

follo"ed for 9& days after the ED visit. The discharge

diagnoses reflected real life practice# and "e !elieve

that very fe" "ere inaccurate.

5n our revie" of the patient records at 9& days to

determine "hether an AC diagnosis "as missed or

if the patient died# "e may have missed a small

num!er of patients presenting to other hospitals.

8o"ever# such misclassifications "ere pro!a!ly fe" and

unlikely to sig- nificantly affect the results of this study.

5n the analysis# patients "ith or "ithout ongoing chest

pain "ere not separated. Fe have no data as to "hether they "ere evaluated or treated differently.

As TnT "as used in the gestalt assessment as "ell

as in deciding the final diagnosis# incorporation !ias

could have !een present. This "as ho"ever pro!a!ly

limited !y the fact that the emergency physicians only

had access to the initial TnT# "hereas the dischargediagnoses "ere most often !ased on repeated TnT

analyses to assess for significant rise or fall.

7inally "e did not have data regarding physician

level of e3perience. 8o"ever# at least in the

assessment of pulmonary em!olism# differences in the

diagnostic accuracy of the gestalt depending on

e3perience are small (;a!rhel et al. %&&).

!gg"stions #or #!rth"r st!*i"s

4any of our results have !road confidence intervals sug-

gesting that a larger study "ith a similar aim "ould

!e prefera!le in order to confirm the findings.

everal clinical decision support tools and risk predic-

tion scores for patients "ith suspected AC have !een

pu!lished# e.g. the 8EA:T score (i3 et al. %&&).

7or any such tool or score to !e clinically useful# they

have to !e at least as good as the gestalt. Fe suggest that

fu- ture studies compare ne" decision support tools

and scores "ith the physician.s gestalt assessment.

5nterest- ingly# it has !een sho"n that the gestalt performs

!etter than the Fells score in the assessment of the

pro!a!ility of pulmonary em!olism ($enalo1a et al. %&'9).

Conclusion Not surprisingly# gestalt "as !etter than its components

!oth at ruling in (,: %) and at ruling out (,: &.&')

AC. The gestalt seemed to overestimate the

likelihood of AC "hen cases "ere assessed as strong

suspicion of AC. Among the components of the

gestalt# the initial TnT and EC "ere superior to the

chest pain history for ruling in AC# "hile pain

history "as superior for ruling out AC. 5n patients

"ith a non-ischemic EC and a normal TnT# a chest

pain history typical of A45 "as not a significant

predictor of A45# !ut a pain typical of =A "as still a

moderately good predictor of =A.

Additional $ileuggested definitions of the different levels of AC

suspicion "ere present on the study forms# and although

they left considera!le room for 2udgment# other (or no)

definitions may have led to some"hat different results.

The definition of typical symptoms of 45 might have

!een su!optimal as it is some"hat non-specific# !ut it is

a definition commonly used in guidelines (Amsterdam

et al. %&'&). Although the physicians "ere instructed

to disregard EC and TnT "hen evaluating the

symptoms# "e cannot e3clude that EC and TnT results

influenced the symptom assessment in some cases.

Additional $ile 12 t!*% #or,.

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for Acute $oronary Syndrome and 8ulmonary Em'olism in 8atients Kith$hest 8ain and Dys!nea( Ann Emer& Med 3#3%926+E25.

/ee )=, $ook E>, Keis'er& M, Sar&ent 0, Kilson $, oldman / #15+% Acute

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/ee )=, 0ouan K, Keis'er& M$, Grand DA, Acam!ora D, Stasiule"icQ $, $o!en D,

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Marsan 0J Jr, Shaver J, Sease /, Shofer >S, Sites >D, =ollander JE #2..+%

Evaluation of a clinical decision rule for youn& adult !atients "ith chest !ain(

Acad Emer& Med 12#1%92E31

Miller $D, /indsell $J, handel"al S, $handra A, 8ollack $L, )iffany G0, =ollander JE,

i'ler KG, =oekstra JK #2..4% s the initial dia&nostic im!ression of Rnoncardiacchest !ainR adeIuate to e-clude cardiac diseaseO Ann Emer& Med 44#%9++E+64

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