title: Acute chest pain-a stepwise approach, the challenge of the correct clinical diagnosis.
abstract: OBJECTIVE
  To assess the safety and the accuracy of a 4 h stepwise diagnostic approach relying on clinical judgement in unselected patients with acute chest pain.
  
  
  METHODS
  Prospective cohort study.
  
  
  METHODS
  Emergency department (ED) of a tertiary care university hospital.
  
  
  METHODS
  1288 unselected patients presenting with acute chest pain.
  
  
  METHODS
  After history and physical examination, clinical judgement (step I), governed the need for further patient evaluation: baseline 12 lead electrocardiogramm (ECG) and laboratory examinations (step II), serial 12 lead ECG and laboratory examinations after 4 h (step III), and 4 h troponin T measurement (step IV) to exclude or to confirm a coronary origin of chest pain. Patients were followed clinically for 6 months for future occurrence of cardiac events (myocardial infarction, percutaneous transluminal coronary angioplasty (PTCA), CABG, cardiac death), any death and for accuracy of the ED diagnosis in non-coronary chest pain patients.
  
  
  RESULTS
  Chest pain was diagnosed to be coronary in origin in 381 and non-coronary in 907 patients, respectively. Cardiac events occurred during follow up in 240 (19%) of 1288 patients, in 233 of 381 (61%) with presumed coronary and seven of 907 (1%) with presumed non-coronary chest pain. Sensitivity, specificity, positive predictive value and negative predictive value for correct detection of coronary chest pain were 97, 86, 61 and 99%, respectively. In non-coronary chest pain patients the agreement between the ED diagnosis and the final diagnosis was good (kappa=0.71, 95% confidence interval (CI) 0.67-0.75).
  
  
  CONCLUSIONS
  The 4 h stepwise approach guided by clinical judgement was safe for ruling out impending cardiac events in unselected patients with acute chest pain. However, more extensive evaluation is necessary for accurate rule-in of coronary chest pain.
authors.affiliation: Department of Emergency Medicine, Medical School, Vienna General Hospital, University of Vienna, Waehringer Guertel 18-20/6, Austria. hans.domanovits@univie.ac.at
authors.forename: Hans
authors.initials: H
authors.lastname: Domanovits
authors.forename: Martin
authors.initials: M
authors.lastname: Schillinger
authors.forename: Monika
authors.initials: M
authors.lastname: Paulis
authors.forename: Fritz
authors.initials: F
authors.lastname: Rauscha
authors.forename: Jana
authors.initials: J
authors.lastname: Thoennissen
authors.forename: Mariam
authors.initials: M
authors.lastname: Nikfardjam
authors.forename: Anton N
authors.initials: AN
authors.lastname: Laggner
mesh_terms: D000208:Acute Disease; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000787:Angina Pectoris / Q000175:diagnosis* / Q000628:therapy; D015906:Angioplasty, Balloon, Coronary; D002637:Chest Pain / Q000175:diagnosis / Q000209:etiology*; D015331:Cohort Studies; D001026:Coronary Artery Bypass; D016757:Death, Sudden, Cardiac; D003937:Diagnosis, Differential; D004562:Electrocardiography; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000175:diagnosis* / Q000628:therapy; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index; D013997:Time Factors