Ruling out coronary heart disease in primary care patients with chest pain: a clinical prediction score

Abstract

BackgroundChest pain raises concern for the possibility of coronary heart disease. Scoring methods have been developed to identify coronary heart disease in emergency settings, but not in primary care.MethodsData were collected from a multicenter Swiss clinical cohort study including 672 consecutive patients with chest pain, who had visited one of 59 family practitioners' offices. Using delayed diagnosis we derived a prediction rule to rule out coronary heart disease by means of a logistic regression model. Known cardiovascular risk factors, pain characteristics, and physical signs associated with coronary heart disease were explored to develop a clinical score. Patients diagnosed with angina or acute myocardial infarction within the year following their initial visit comprised the coronary heart disease group.ResultsThe coronary heart disease score was derived from eight variables: age, gender, duration of chest pain from 1 to 60 minutes, substernal chest pain location, pain increasing with exertion, absence of tenderness point at palpation, cardiovascular risks factors, and personal history of cardiovascular disease. Area under the receiver operating characteristics curve was of 0.95 with a 95% confidence interval of 0.92; 0.97. From this score, 413 patients were considered as low risk for values of percentile 5 of the coronary heart disease patients. Internal validity was confirmed by bootstrapping. External validation using data from a German cohort (Marburg, n = 774) revealed a receiver operating characteristics curve of 0.75 (95% confidence interval, 0.72; 0.81) with a sensitivity of 85.6% and a specificity of 47.2%.ConclusionsThis score, based only on history and physical examination, is a complementary tool for ruling out coronary heart disease in primary care patients complaining of chest pain.

In primary care, when is chest pain due to coronary artery disease?

“…The resulting "any three of five" rule could hardly be easier to use, and -almost unique in prediction-rule research -there was no loss of predictive power in the validation cohort. It is instructive to compare this with the companion paper, 8 in which a comparatively complex risk score derived from the Swiss data was less successful in external validation. This may illustrate Dawes' heuristic argument that the simplest decision rules are also the most robust.…”

Chest pain for coronary heart disease in general practice: clinical judgement and a clinical decision rule

“…1,4,15 To the authors' knowledge, this is the first study that investigated how one of these clinical decision rules adds to the GP's judgement. This study gave some British Journal of General Practice, November 2015 e751 insights into how different ways of using the MHS may affect the accuracy of the initial diagnostic approach to chest pain patients.…”

Ruling out coronary artery disease in primary care: development and validation of a simple prediction rule

“…[14][15][16] A clinical prediction score to rule out coronary artery disease in general practice has been developed. 17 However, it did not perform well when validated externally. The aim of our study was to develop a simple, valid and usable prediction score based on signs and symptoms to help primary care physicians rule out coronary artery disease in patients presenting with chest pain.…”