Bedside diagnosis of coronary artery disease: a systematic review.
OBJECTIVE
To assess the accuracy of bedside findings for diagnosing coronary artery disease and acute myocardial infarction.


METHODS
A MEDLINE search was performed to retrieve articles published from January 1966 to January 2003 that were relevant to the bedside diagnosis of coronary disease in adults.


RESULTS
In patients with stable, intermittent chest pain, the most useful bedside predictors for a diagnosis of coronary disease were found to be the presence of typical angina (likelihood ratio [LR]=5.8; 95% confidence interval [CI]: 4.2 to 7.8), serum cholesterol level >300 mg/dL (LR=4.0; 95% CI: 2.5 to 6.3), history of prior myocardial infarction (LR=3.8; 95% CI: 2.1 to 6.8), and age >70 years (LR=2.6; 95% CI: 1.8 to 4.0). Nonanginal chest pain (LR=0.1; 95% CI: 0.1 to 0.2), pain duration >30 minutes (LR=0.1; 95% CI: 0.0 to 0.9), and intermittent dysphagia (LR=0.2; 95% CI: 0.1 to 0.8) argued against a diagnosis of coronary disease. In patients with acute chest pain, the most important bedside predictors for a diagnosis of myocardial infarction were new ST elevation (LR=22; 95% CI: 16 to 30), new Q waves (LR=22; 95% CI: 7.6 to 62), and new ST depression (LR=4.5; 95% CI: 3.6 to 5.6). A normal electrocardiogram (LR=0.2; 95% CI: 0.1 to 0.3), chest wall tenderness (LR=0.3; 95% CI: 0.2 to 0.4), and pain that was pleuritic (LR=0.2; 95% CI: 0.2 to 0.3), sharp (LR=0.3; 95% CI: 0.2 to 0.5), or positional (LR=0.3; 95% CI: 0.2 to 0.5) argued against the diagnosis of myocardial infarction.


CONCLUSIONS
The accuracy of bedside predictors depends on the clinical setting. In the evaluation of stable, intermittent chest pain, a patient's description of pain was found to be the most important predictor of underlying coronary disease. In the evaluation of acute chest pain, the electrocardiogram was the most useful bedside predictor for a diagnosis of myocardial infarction. Aside from the extremes in cholesterol values, the analysis of traditional risk factors changed the probability of coronary disease or myocardial infarction very little or not at all.
Chun
Andrea Akita
AA
Department of General Internal Medicine, University of Washington, Harborview Medical Center, Seattle 98104-2499, USA. anchun@u.washington.edu
McGee
Steven R
SR
D000208:Acute Disease; D000328:Adult; D000368:Aged; D000787:Angina Pectoris / Q000209:etiology; D001112:Arcus Senilis / Q000175:diagnosis / Q000209:etiology; D003324:Coronary Artery Disease / Q000175:diagnosis* / Q000209:etiology; D003680:Deglutition Disorders / Q000209:etiology; D003937:Diagnosis, Differential; D004562:Electrocardiography / Q000592:standards*; D005260:Female; D006801:Humans; D006937:Hypercholesterolemia / Q000097:blood / Q000150:complications / Q000175:diagnosis; D016013:Likelihood Functions; D008297:Male; D008487:Medical History Taking / Q000379:methods / Q000592:standards*; D008875:Middle Aged; D010808:Physical Examination / Q000379:methods / Q000592:standards*; D019095:Point-of-Care Systems / Q000592:standards*; D011237:Predictive Value of Tests; D015203:Reproducibility of Results; D018570:Risk Assessment; D012307:Risk Factors; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D013997:Time Factors