title: Accuracy of gestalt perception of acute chest pain in predicting coronary artery disease.
abstract: OBJECTIVE
  To test accuracy and reproducibility of gestalt to predict obstructive coronary artery disease (CAD) in patients with acute chest pain.
  
  
  METHODS
  We studied individuals who were consecutively admitted to our Chest Pain Unit. At admission, investigators performed a standardized interview and recorded 14 chest pain features. Based on these features, a cardiologist who was blind to other clinical characteristics made unstructured judgment of CAD probability, both numerically and categorically. As the reference standard for testing the accuracy of gestalt, angiography was required to rule-in CAD, while either angiography or non-invasive test could be used to rule-out. In order to assess reproducibility, a second cardiologist did the same procedure.
  
  
  RESULTS
  In a sample of 330 patients, the prevalence of obstructive CAD was 48%. Gestalt's numerical probability was associated with CAD, but the area under the curve of 0.61 (95%CI: 0.55-0.67) indicated low level of accuracy. Accordingly, categorical definition of typical chest pain had a sensitivity of 48% (95%CI: 40%-55%) and specificity of 66% (95%CI: 59%-73%), yielding a negligible positive likelihood ratio of 1.4 (95%CI: 0.65-2.0) and negative likelihood ratio of 0.79 (95%CI: 0.62-1.02). Agreement between the two cardiologists was poor in the numerical classification (95% limits of agreement = -71% to 51%) and categorical definition of typical pain (Kappa = 0.29; 95%CI: 0.21-0.37).
  
  
  CONCLUSIONS
  Clinical judgment based on a combination of chest pain features is neither accurate nor reproducible in predicting obstructive CAD in the acute setting.
authors.affiliation: Cláudio Marcelo Bittencourt das Virgens, Márcia Noya-Rabelo, Luís Cláudio Lemos Correia, Department of Cardiology, Hospital São Rafael, Salvador, Bahia 41253-190, Brazil.
authors.forename: Cláudio Marcelo Bittencourt
authors.initials: CM
authors.lastname: das Virgens
authors.affiliation: Cláudio Marcelo Bittencourt das Virgens, Márcia Noya-Rabelo, Luís Cláudio Lemos Correia, Department of Cardiology, Hospital São Rafael, Salvador, Bahia 41253-190, Brazil.
authors.forename: Laudenor
authors.initials: L
authors.lastname: Lemos
authors.affiliation: Cláudio Marcelo Bittencourt das Virgens, Márcia Noya-Rabelo, Luís Cláudio Lemos Correia, Department of Cardiology, Hospital São Rafael, Salvador, Bahia 41253-190, Brazil.
authors.forename: Márcia
authors.initials: M
authors.lastname: Noya-Rabelo
authors.affiliation: Cláudio Marcelo Bittencourt das Virgens, Márcia Noya-Rabelo, Luís Cláudio Lemos Correia, Department of Cardiology, Hospital São Rafael, Salvador, Bahia 41253-190, Brazil.
authors.forename: Manuela Campelo
authors.initials: MC
authors.lastname: Carvalhal
authors.affiliation: Cláudio Marcelo Bittencourt das Virgens, Márcia Noya-Rabelo, Luís Cláudio Lemos Correia, Department of Cardiology, Hospital São Rafael, Salvador, Bahia 41253-190, Brazil.
authors.forename: Antônio Maurício Dos Santos
authors.initials: AM
authors.lastname: Cerqueira Junior
authors.affiliation: Cláudio Marcelo Bittencourt das Virgens, Márcia Noya-Rabelo, Luís Cláudio Lemos Correia, Department of Cardiology, Hospital São Rafael, Salvador, Bahia 41253-190, Brazil.
authors.forename: Fernanda Oliveira de Andrade
authors.initials: FO
authors.lastname: Lopes
authors.affiliation: Cláudio Marcelo Bittencourt das Virgens, Márcia Noya-Rabelo, Luís Cláudio Lemos Correia, Department of Cardiology, Hospital São Rafael, Salvador, Bahia 41253-190, Brazil.
authors.forename: Nicole Cruz
authors.initials: NC
authors.lastname: de Sá
authors.affiliation: Cláudio Marcelo Bittencourt das Virgens, Márcia Noya-Rabelo, Luís Cláudio Lemos Correia, Department of Cardiology, Hospital São Rafael, Salvador, Bahia 41253-190, Brazil.
authors.forename: Jéssica Gonzalez
authors.initials: JG
authors.lastname: Suerdieck
authors.affiliation: Cláudio Marcelo Bittencourt das Virgens, Márcia Noya-Rabelo, Luís Cláudio Lemos Correia, Department of Cardiology, Hospital São Rafael, Salvador, Bahia 41253-190, Brazil.
authors.forename: Thiago Menezes Barbosa
authors.initials: TM
authors.lastname: de Souza
authors.affiliation: Cláudio Marcelo Bittencourt das Virgens, Márcia Noya-Rabelo, Luís Cláudio Lemos Correia, Department of Cardiology, Hospital São Rafael, Salvador, Bahia 41253-190, Brazil.
authors.forename: Vitor Calixto de Almeida
authors.initials: VC
authors.lastname: Correia
authors.affiliation: Cláudio Marcelo Bittencourt das Virgens, Márcia Noya-Rabelo, Luís Cláudio Lemos Correia, Department of Cardiology, Hospital São Rafael, Salvador, Bahia 41253-190, Brazil.
authors.forename: Gabriella Sant'Ana
authors.initials: GS
authors.lastname: Sodré
authors.affiliation: Cláudio Marcelo Bittencourt das Virgens, Márcia Noya-Rabelo, Luís Cláudio Lemos Correia, Department of Cardiology, Hospital São Rafael, Salvador, Bahia 41253-190, Brazil.
authors.forename: André Barcelos
authors.initials: AB
authors.lastname: da Silva
authors.affiliation: Cláudio Marcelo Bittencourt das Virgens, Márcia Noya-Rabelo, Luís Cláudio Lemos Correia, Department of Cardiology, Hospital São Rafael, Salvador, Bahia 41253-190, Brazil.
authors.forename: Felipe Kalil Beirão
authors.initials: FK
authors.lastname: Alexandre
authors.affiliation: Cláudio Marcelo Bittencourt das Virgens, Márcia Noya-Rabelo, Luís Cláudio Lemos Correia, Department of Cardiology, Hospital São Rafael, Salvador, Bahia 41253-190, Brazil.
authors.forename: Felipe Rodrigues Marques
authors.initials: FR
authors.lastname: Ferreira
authors.affiliation: Cláudio Marcelo Bittencourt das Virgens, Márcia Noya-Rabelo, Luís Cláudio Lemos Correia, Department of Cardiology, Hospital São Rafael, Salvador, Bahia 41253-190, Brazil.
authors.forename: Luís Cláudio Lemos
authors.initials: LC
authors.lastname: Correia
keywords: Acute chest pain; Acute coronary syndrome; Clinical judgment; Coronary artery disease; Gestalt