How well does the history and physical perform in diagnosing acute myocardial infarction or acute coronary syndromes?

In patients with chest pain, the history and physical is not very helpful in diagnosing acute myocardial infarction (AMI) or acute coronary syndromes (ACS). In patients for whom the clinical suspicion of AMI or ACS is low, the presence of chest wall tenderness rules them out. (LOE = 2a)

Bruyninckx R, Aertgeerts B, Bruyninckx P, Buntinx F. Signs and symptoms in diagnosing acute myocardial infarction and acute coronary syndrome: a diagnostic meta-analysis. Br J Gen Pract 2008;58(547):105-111.  [PMID:18307844]

Meta-analysis (other)

Unknown/not stated

Various (meta-analysis)

These authors searched multiple databases and bibliographies and contacted experts to find studies that assessed the diagnostic value of the following symptoms and signs in identifying patients with AMI or ACS: radiating pain; oppressive pain; nausea and/or vomiting; diaphoresis; and absence of chest wall tenderness on palpation. The authors provided no justification for why these symptoms and signs were chosen. Two reviewers independently screened the titles of potential articles and a third reviewer resolved any disagreements that occurred. The authors assessed each study's methodologic quality. They found 16 studies of unselected patients (for the lowest likelihood of being biased toward more severe cases or those with a higher likelihood of having AMI or ACS). Since the gold standard used in many of the studies also included elements from the history, the diagnostic value will be exaggerated. In spite of this biasing effect, the history and physical was nearly useless, with one exception. The presence of chest wall tenderness was very good at ruling out AMI or ACS in patients in whom the clinical suspicion was low.