Clinical predictors of acute coronary syndromes in patients with undifferentiated chest pain

S W Goodacre, K Angelini, J Arnold, S Revill, F Morris
QJM: Monthly Journal of the Association of Physicians 2003, 96 (12): 893-8

BACKGROUND: Patients with acute, undifferentiated chest pain present a frequent diagnostic challenge to clinicians. Clinical features are often used to determine which patients may have acute coronary syndrome (ACS).

AIM: To identify clinical features that independently predict ACS in patients with acute, undifferentiated chest pain.

DESIGN: Prospective study of patients enrolled in a randomized controlled trial.

METHODS: The presenting characteristics of participants in the ESCAPE randomized trial of chest pain unit vs. routine care were recorded in a standardized manner. Follow-up consisted of troponin T measurement at 2 days, postal questionnaire at 1 month, and telephone contact at 6 months. ACS was defined as elevated troponin T at 2 days or major adverse cardiac event within 30 days of presentation. Multivariate analysis identified independent clinical predictors of ACS.

RESULTS: ACS was diagnosed in 77 (7.9%) of the 972 patients recruited. The following characteristics were independent predictors of ACS (odds ratio, p): age (1.09, p < 0.001), male gender (8.6, p < 0.001), indigestion or burning-type pain (3.0, p = 0.034), pain radiating to the left (2.4, p = 0.013) or right (5.7, p < 0.001) arm, vomiting (3.5, p = 0.007), and previous (5.1, p < 0.001) or current (3.7, p < 0.001) smoking.

DISCUSSION: In addition to previously recognized predictors of ACS, it appears that indigestion or burning type pain predicts ACS in patients attending the emergency department with acute, undifferentiated chest pain. Diagnosis of acute 'gastro-oesophageal' chest pain should be avoided in this setting.

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