Clinical assessment of patients with chest pain; a systematic review of predictive tools

Abstract

BackgroundThe clinical assessment of patients with chest pain of recent onset remains difficult. This study presents a critical review of clinical predictive tools for the assessment of patients with chest pain.MethodsSystematic review of observational studies and estimation of probabilities of coronary artery disease (CAD) in patients with chest pain. Searches were conducted in PubMed, Embase, Scopus, and Web of Science to identify studies reporting tools, with at least three variables from clinical history, physical examination or ECG, produced with multivariate analysis, to estimate probabilities of CAD in patients with chest pain of recent onset, published from inception of the database to the 31st July 2015. The references of previous relevant reviews were hand searched. The methodological quality was assessed with standard criteria. Since the incidence of CAD has changed in the past few decades, the date of publication was acknowledged to be relevant in order to use the tool in clinical practice, and more recent papers were considered more relevant. Probabilities of CAD according to the studies of highest quality were estimated and the evidence provided was graded.ResultsTwelve papers were included out of the 19126 references initially identified. The methodological quality of all of them was high. The clinical characteristics of the chest pain, age, past medical history of cardiovascular disease, gender, and abnormalities in the ECG were the predictors of CAD most commonly reported across the studies. The most recent papers, with highest methodological quality, and most practical for use in clinical settings, reported prediction or exclusion of CAD with area under the curve 0.90 in Primary Care, 0.91 in Emergency department, and 0.79 in Cardiology. These papers provide evidence of high level (1B) and the recommendation to use their results in the management of patients with chest pain is strong (A).ConclusionsThe risk of CAD can be estimated on clinical grounds in patients with chest pain in different clinical settings with high accuracy. The estimation of probabilities of CAD presented in these studies could be used for a better management of patients with chest pain and also in the development of future predictive tools.Electronic supplementary materialThe online version of this article (doi:10.1186/s12872-016-0196-4) contains supplementary material, which is available to authorized users.

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“…CDRs have been coined as an idea to aid in the diagnostic process and to make safe and efficient referral decisions. A prior systematic review on this topic showed that CDRs are not sensitive enough to safely rule out CAD in primary care patients 20. We performed an updated systematic review in which we included both derivation, validation and comparative studies with clinical judgement (‘gestalt’).…”

Evaluation and comparison of six GRACE models for the stratification of undifferentiated chest pain in the emergency department

“…Chest pain and related symptoms are the most common reasons for patients to present to the emergency department (ED) [1,2], and present extremely heterogeneous with a wide spectrum of underlying conditions ranging from lethal diseases such as acute myocardial infarction (AMI) to minor acute problems such as intercostal neuralgia. Ruling in or ruling out high-risk conditions in a timely manner is of great importance and a great challenge [3][4][5][6]. Furthermore, the majority of undifferentiated acute chest pain patients are low risk and do not require further invasive tests or admission [6,7].…”