Evidence-Based Answers

Evidence Central™ is an integrated web and mobile solution that helps clinicians quickly answer etiology, diagnosis, treatment, and prognosis questions using the latest evidence-based research.


Evidence Central for Mobile Devices

Evidence Central iOS iPhone iPad Android

Evidence Central from Unbound Medicine, available for iOS® and Android™, is optimized for each platform and features superior navigation, so answers are easy to find at the bedside or anywhere they’re needed. Learn More

Word of the Day

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)

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)


Outpatient (primary care)

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.


Site Licenses

Site license

Site Licenses are available for schools, universities, hospitals, government agencies, and companies. For more information, contact us.