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Improved primary care diagnosis of coronary disease as cause of chest pain

Clinical Question:
Can a simple clinical rule assist primary care physicians in the diagnosis of chest pain?

Bottom Line:
This study provides important guidance for the diagnosis of outpatient coronary artery disease (CAD). Patients with less than 2 of 5 key symptoms have a very low likelihood of coronary artery disease (< 1%). (LOE = 1b)

Reference:
Bösner S, Haasenritter J, Becker A, et al. Ruling out coronary artery disease in primary care: development and validation of a simple prediction rule. CMAJ 2010 ;182(12):1295-1300.  [PMID:20603345]

Study Design:
Cohort (prospective)

Funding:
Government

Setting:
Outpatient (primary care)

Synopsis:
This is the second in a series of reports from a large prospective cohort study of chest pain in primary care patients. Consecutive patients older than 35 years presenting with nontraumatic chest pain to 1 of 74 German general practitioners (GPs) were recruited. Each had a standardized history and physical examination and a diagnostic evaluation as recommended by the individual GP. Patients were phoned at 6 weeks and 6 months to determine the prognosis and final diagnosis, and any hospital discharge letters and GP records were also reviewed at 6 months. A limitation of the study was that every patient did not undergo a definitive test, such as coronary angiography; the study rests on the assumption that if a patient presented with chest pain, and it was caused by CAD, it would be diagnosed during the subsequent 6 months. The average age of participants was 59 years and 56% were women. The 5 best independent predictors of a final diagnosis of CAD as a cause of primary care chest pain were age (at least 65 years in women or at least 55 years in men); a history of known CAD, occlusive vascular disease, or cerebrovascular disease; pain worse during exercise; pain not reproducible by palpation; and the patient assumes pain is of cardiac origin. They externally validated this 5-point score using data from a similar Swiss study of primary care patients with chest pain. In this validation group, patients with 0 or 1 risk factors had a very low likelihood of CAD (1/271, 0.4%), those with 2 or 3 risk factors had a moderate likelihood of CAD (39/332 or 12%), and those with 4 or 5 risk factors had a high risk of CAD (45/69, 65%). Performance was similar in the validation group as in the original derivation group. Using a dichotomous cut-off value of 3 or more points as high risk, the positive likelihood ratio was 4.52 and the negative likelihood ratio was 0.16.

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