title: Clinical assessment of patients with chest pain; a systematic review of predictive tools.
abstract: BACKGROUND
  The clinical assessment of patients with chest pain of recent onset remains difficult. This study presents a critical review of clinical predictive tools for the assessment of patients with chest pain.
  
  
  METHODS
  Systematic review of observational studies and estimation of probabilities of coronary artery disease (CAD) in patients with chest pain. Searches were conducted in PubMed, Embase, Scopus, and Web of Science to identify studies reporting tools, with at least three variables from clinical history, physical examination or ECG, produced with multivariate analysis, to estimate probabilities of CAD in patients with chest pain of recent onset, published from inception of the database to the 31st July 2015. The references of previous relevant reviews were hand searched. The methodological quality was assessed with standard criteria. Since the incidence of CAD has changed in the past few decades, the date of publication was acknowledged to be relevant in order to use the tool in clinical practice, and more recent papers were considered more relevant. Probabilities of CAD according to the studies of highest quality were estimated and the evidence provided was graded.
  
  
  RESULTS
  Twelve papers were included out of the 19126 references initially identified. The methodological quality of all of them was high. The clinical characteristics of the chest pain, age, past medical history of cardiovascular disease, gender, and abnormalities in the ECG were the predictors of CAD most commonly reported across the studies. The most recent papers, with highest methodological quality, and most practical for use in clinical settings, reported prediction or exclusion of CAD with area under the curve 0.90 in Primary Care, 0.91 in Emergency department, and 0.79 in Cardiology. These papers provide evidence of high level (1B) and the recommendation to use their results in the management of patients with chest pain is strong (A).
  
  
  CONCLUSIONS
  The risk of CAD can be estimated on clinical grounds in patients with chest pain in different clinical settings with high accuracy. The estimation of probabilities of CAD presented in these studies could be used for a better management of patients with chest pain and also in the development of future predictive tools.
authors.affiliation: Centre for Primary Care and Public Health, Queen Mary University of London, Yvonne Carter Building, 58 Turner Street, London, E1 2AB, UK. l.garcia-morzon@qmul.ac.uk.
authors.forename: Luis
authors.initials: L
authors.lastname: Ayerbe
authors.affiliation: Family Medicine Unit, Department of Medicine, Autónoma University of Madrid, Madrid, Spain.
authors.forename: Esteban
authors.initials: E
authors.lastname: González
authors.affiliation: Centre for Primary Care and Public Health, Queen Mary University of London, Yvonne Carter Building, 58 Turner Street, London, E1 2AB, UK.
authors.forename: Valentina
authors.initials: V
authors.lastname: Gallo
authors.affiliation: Centre for Primary Care and Public Health, Queen Mary University of London, Yvonne Carter Building, 58 Turner Street, London, E1 2AB, UK.
authors.forename: Claire L
authors.initials: CL
authors.lastname: Coleman
authors.affiliation: Department of Cardiology, Barts Health NHS Trust, London, UK.
authors.forename: Andrew
authors.initials: A
authors.lastname: Wragg
authors.affiliation: Centre for Primary Care and Public Health, Queen Mary University of London, Yvonne Carter Building, 58 Turner Street, London, E1 2AB, UK.
authors.forename: John
authors.initials: J
authors.lastname: Robson
mesh_terms: D000367:Age Factors; D019540:Area Under Curve; D002309:Cardiology; D002637:Chest Pain / Q000175:diagnosis* / Q000209:etiology; D003324:Coronary Artery Disease / Q000150:complications / Q000175:diagnosis*; D003661:Decision Support Techniques; D004562:Electrocardiography; D004636:Emergency Service, Hospital; D006801:Humans; D017202:Myocardial Ischemia / Q000150:complications / Q000175:diagnosis*; D064887:Observational Studies as Topic; D011320:Primary Health Care; D012737:Sex Factors