Diagnosis

Individual chest pain characteristics had low accuracy for detecting acute MI in both men and women

Rubini Gimenez M, Reiter M, Twerenbold R, et al. Sex-specific chest pain characteristics in the early diagnosis of acute myocardial infarction. JAMA Intern Med. 2014;174:241-9.

Clinical impact ratings: F ★★★★★★✩ E ★★★★★✩✩ C ★★★★★✩✩ Question In the emergency department, do sex-specific chest pain characteristics (CPCs) detect acute myocardial infarction (AMI) in women?

Methods Design: Comparison of CPCs, assessed in patient interviews in the emergency department, with adjudicated diagnosis of AMI at 90 days (Advantageous Predictors of Acute Coronary Syndrome Evaluation [APACE] study). ClinicalTrials.gov NCT00470587. Setting: 9 centers in Italy, Spain, and Switzerland. Patients: 2475 consecutive patients ≥ 18 years of age (68% men, median age 59 y in men and 70 y in women) who presented to the emergency department with acute chest pain onset or peak in the past 12 hours. Exclusion criteria included terminal kidney failure needing regular dialysis. Description of tests: 34 individual CPCs including pain onset and dynamics (sudden onset, increasing, stable, decreasing), pain duration (< 2 min, 2 to 30 min, > 30 min), prior pain episodes (none, ≤ 30 d, > 30 d), pain quality (pressure-like, stabbing, burning or aching, with dyspnea), pain location and size (midchest, left chest, right chest, supramammillary, inframamillary, ≥ 3-cm diameter), pain radiation (none, throat, left shoulder/arm, right shoulder/arm, both shoulders, back, abdomen), pain severity, aggravating factors (exertion, breathing, movement, palpation, emotional stress), and pain relieved by nitrates. Diagnostic standard: Myocardial necrosis (≥ 1 cardiac troponin level > 99th percentile or conventional cardiac troponin level > 10% imprecision value if < 99th percentile, and significant change over time) and findings consistent with myocardial ischemia. Diagnosis was adjudicated by 2 independent cardiologists at 90-day follow-up based on medical record data including patient history and physical examination; CPCs; lesion severity; electrocardiography (ECG); echocardiography; angiography; and laboratory, radiologic, and cardiac exercise testing. Outcome: Likelihood ratios for a positive test result (LRs+).

Main results 18% of women and 22% of men had AMI. LRs+ of CPCs for AMI ranged from 0.25 (95% CI 0.11 to 0.57) in men and 0.48 (CI 0.15 to 1.55) in women with pain duration < 2 minutes to 2.27 (CI 1.79 to 2.87) in men and 1.63 (CI 1.02 to 2.58) in LRs+ of chest pain characteristics for detecting AMI in men and women in the emergency department* Chest pain characteristic

LR+ (95% CI)

P value for interaction

Men

Women

Pain duration 2 to 30 min

1.06 (1.00 to 1.13)

0.73 (0.50 to 1.06)

0.01

Pain duration > 30 min

0.99 (0.91 to 1.08)

1.13 (1.02 to 1.25)

0.04

Decreasing pain intensity

1.10 (0.91 to 1.32)

0.72 (0.50 to 1.05)

0.04

*AMI = acute myocardial infarction; diagnostic terms defined in Glossary.

18 March 2014 | ACP Journal Club | Volume 160 • Number 6 Downloaded From: https://annals.org/ by a Tufts University User on 08/03/2017

women with pain radiating to the right shoulder or arm. LRs+ for AMI differed between men and women with pain duration 2 to 30 minutes or > 30 minutes, or decreasing pain intensity (Table); LRs+ of other individual CPCs or combinations of 2 CPCs for AMI did not differ between men and women.

Conclusion In the emergency department, individual chest pain characteristics had low accuracy for detecting acute myocardial infarction; most had similar likelihood ratios in women and men. Sources of funding: Swiss National Science Foundation; Swiss Heart Foundation; Cardiovascular Research Foundation Basel; University of Basel; University Hospital Basel. For correspondence: Dr. C. Mueller, University Hospital Basel, Basel, Switzerland. E-mail [email protected]. ■

Commentary One of the biggest diagnostic challenges in the emergency department is the evaluation of chest pain. Of note, the diagnosis of AMI triggers time-dependent therapeutic interventions that considerably reduce morbidity and mortality, whereas misdiagnosis has important medical and legal ramifications. The concern that sex-specific differences in symptom presentation might disadvantage the diagnosis of AMI in women has been put to rest by Rubini Gimenez and colleagues. They carefully documented 34 CPCs in 2475 patients and found none that would improve diagnostic accuracy in women compared with men. Moreover, acute chest pain history does not accurately differentiate AMI from other causes of chest pain in men or women because of the wide variability in symptom presentations. Rather, chest pain even remotely suggestive of AMI should trigger an ECG within 10 minutes of hospital presentation to screen for ST-elevation MI and measurement of serial cardiac troponin values to diagnose or exclude AMI regardless of sex. The diagnosis of AMI is based on detection of a rise and fall of cardiac troponin values with ≥ 1 of the following: 1) symptoms of ischemia, 2) new or presumed new significant ST-segment T-wave changes or new left bundle branch block, 3) development of pathologic Q waves in the ECG, 4) imaging evidence of new loss of viable myocardium or new regional wall motion abnormality, or 5) identification of an intracoronary thrombus by angiography or autopsy (1). Therefore, it takes an elevated troponin value, not a chest pain history, to diagnose AMI, but troponin has to be elevated in a clinical context consistent with AMI. When the new high-sensitivity troponin assays are available, elevated troponin levels will increasingly be reported in non-AMI patients, and CPCs will be most important for excluding false-positive results. Eric R. Bates, MD University of Michigan Ann Arbor, Michigan, USA Reference 1. Thygesen K, Alpert JS, Jaffe AS, et al; Joint ESC/ACCF/AHA/WHF Task Force for the Universal Definition of Myocardial Infarction. Third universal definition of myocardial infarction. Circulation. 2012;126:2020-35.

© 2014 American College of Physicians

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Individual chest pain characteristics had low accuracy for detecting acute MI in both men and women.

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