title: Ruling out coronary heart disease in primary care patients with chest pain: a clinical prediction score.
abstract: BACKGROUND
  Chest pain raises concern for the possibility of coronary heart disease. Scoring methods have been developed to identify coronary heart disease in emergency settings, but not in primary care.
  
  
  METHODS
  Data were collected from a multicenter Swiss clinical cohort study including 672 consecutive patients with chest pain, who had visited one of 59 family practitioners' offices. Using delayed diagnosis we derived a prediction rule to rule out coronary heart disease by means of a logistic regression model. Known cardiovascular risk factors, pain characteristics, and physical signs associated with coronary heart disease were explored to develop a clinical score. Patients diagnosed with angina or acute myocardial infarction within the year following their initial visit comprised the coronary heart disease group.
  
  
  RESULTS
  The coronary heart disease score was derived from eight variables: age, gender, duration of chest pain from 1 to 60 minutes, substernal chest pain location, pain increasing with exertion, absence of tenderness point at palpation, cardiovascular risks factors, and personal history of cardiovascular disease. Area under the receiver operating characteristics curve was of 0.95 with a 95% confidence interval of 0.92; 0.97. From this score, 413 patients were considered as low risk for values of percentile 5 of the coronary heart disease patients. Internal validity was confirmed by bootstrapping. External validation using data from a German cohort (Marburg, n = 774) revealed a receiver operating characteristics curve of 0.75 (95% confidence interval, 0.72; 0.81) with a sensitivity of 85.6% and a specificity of 47.2%.
  
  
  CONCLUSIONS
  This score, based only on history and physical examination, is a complementary tool for ruling out coronary heart disease in primary care patients complaining of chest pain.
authors.affiliation: Department of Ambulatory Care and Community Medicine, University of Lausanne, Switzerland. bernard.favrat@hospvd.ch
authors.forename: Baris
authors.initials: B
authors.lastname: Gencer
authors.forename: Paul
authors.initials: P
authors.lastname: Vaucher
authors.forename: Lilli
authors.initials: L
authors.lastname: Herzig
authors.forename: François
authors.initials: F
authors.lastname: Verdon
authors.forename: Christiane
authors.initials: C
authors.lastname: Ruffieux
authors.forename: Stefan
authors.initials: S
authors.lastname: Bösner
authors.forename: Bernard
authors.initials: B
authors.lastname: Burnand
authors.forename: Thomas
authors.initials: T
authors.lastname: Bischoff
authors.forename: Norbert
authors.initials: N
authors.lastname: Donner-Banzhoff
authors.forename: Bernard
authors.initials: B
authors.lastname: Favrat
mesh_terms: D000328:Adult; D000368:Aged; D019540:Area Under Curve; D002637:Chest Pain / Q000175:diagnosis* / Q000209:etiology; D015331:Cohort Studies; D003327:Coronary Disease / Q000175:diagnosis*; D003937:Diagnosis, Differential; D004562:Electrocardiography; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D011237:Predictive Value of Tests; D011320:Primary Health Care / Q000379:methods; D012372:ROC Curve; D015203:Reproducibility of Results; D012307:Risk Factors