title: Coronary heart disease in primary care: accuracy of medical history and physical findings in patients with chest pain--a study protocol for a systematic review with individual patient data.
abstract: BACKGROUND
  Chest pain is a common complaint in primary care, with coronary heart disease (CHD) being the most concerning of many potential causes. Systematic reviews on the sensitivity and specificity of symptoms and signs summarize the evidence about which of them are most useful in making a diagnosis. Previous meta-analyses are dominated by studies of patients referred to specialists. Moreover, as the analysis is typically based on study-level data, the statistical analyses in these reviews are limited while meta-analyses based on individual patient data can provide additional information. Our patient-level meta-analysis has three unique aims. First, we strive to determine the diagnostic accuracy of symptoms and signs for myocardial ischemia in primary care. Second, we investigate associations between study- or patient-level characteristics and measures of diagnostic accuracy. Third, we aim to validate existing clinical prediction rules for diagnosing myocardial ischemia in primary care. This article describes the methods of our study and six prospective studies of primary care patients with chest pain. Later articles will describe the main results.
  
  
  METHODS
  We will conduct a systematic review and IPD meta-analysis of studies evaluating the diagnostic accuracy of symptoms and signs for diagnosing coronary heart disease in primary care. We will perform bivariate analyses to determine the sensitivity, specificity and likelihood ratios of individual symptoms and signs and multivariate analyses to explore the diagnostic value of an optimal combination of all symptoms and signs based on all data of all studies. We will validate existing clinical prediction rules from each of the included studies by calculating measures of diagnostic accuracy separately by study.
  
  
  CONCLUSIONS
  Our study will face several methodological challenges. First, the number of studies will be limited. Second, the investigators of original studies defined some outcomes and predictors differently. Third, the studies did not collect the same standard clinical data set. Fourth, missing data, varying from partly missing to fully missing, will have to be dealt with.Despite these limitations, we aim to summarize the available evidence regarding the diagnostic accuracy of symptoms and signs for diagnosing CHD in patients presenting with chest pain in primary care.
  
  
  BACKGROUND
  Centre for Reviews and Dissemination (University of York): CRD42011001170.
authors.affiliation: Department of General Practice/ Family Medicine, University of Marburg, Marburg, D-35032, Germany. haasenri@staff.uni-marburg.de
authors.forename: Jörg
authors.initials: J
authors.lastname: Haasenritter
authors.forename: Marc
authors.initials: M
authors.lastname: Aerts
authors.forename: Stefan
authors.initials: S
authors.lastname: Bösner
authors.forename: Frank
authors.initials: F
authors.lastname: Buntinx
authors.forename: Bernard
authors.initials: B
authors.lastname: Burnand
authors.forename: Lilli
authors.initials: L
authors.lastname: Herzig
authors.forename: J André
authors.initials: JA
authors.lastname: Knottnerus
authors.forename: Girma
authors.initials: G
authors.lastname: Minalu
authors.forename: Staffan
authors.initials: S
authors.lastname: Nilsson
authors.forename: Walter
authors.initials: W
authors.lastname: Renier
authors.forename: Carol
authors.initials: C
authors.lastname: Sox
authors.forename: Harold
authors.initials: H
authors.lastname: Sox
authors.forename: Norbert
authors.initials: N
authors.lastname: Donner-Banzhoff
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002637:Chest Pain / Q000175:diagnosis*; D003327:Coronary Disease / Q000175:diagnosis*; D005260:Female; D006801:Humans; D016013:Likelihood Functions; D008297:Male; D008487:Medical History Taking / Q000706:statistics & numerical data*; D008875:Middle Aged; D015999:Multivariate Analysis; D010808:Physical Examination / Q000379:methods / Q000706:statistics & numerical data*; D011320:Primary Health Care / Q000379:methods*; D012680:Sensitivity and Specificity; D000078202:Systematic Reviews as Topic; D055815:Young Adult; D015201:Meta-Analysis as Topic