A chest pain score for stratifying the risk of coronary artery disease in patients having day case coronary angiography

The rapid access chest pain clinic: unmet distress and disability

AIMS

To determine the characteristics, clinical needs and level of health-care use of patients with non-cardiac (NCCP) and cardiac-chest pain (CCP) attending a Rapid Access Chest Pain Clinic in an inner-London Hospital.

METHODS

A cross-sectional comparison of NCCP and CCP patients on measures of pain, mood, beliefs, somatic symptoms and use of services completed by patients attending the Rapid Access Chest Pain Clinic over an 18-month period.

RESULTS

There were no significant differences between NCCP and CCP patients in terms of chest pain frequency, duration or severity or associated distress; however, NCCP were younger (53 vs. 60, OR = 1.05) and reported 'atypical' pain more frequently (82% vs. 50%, OR = 3.72). The NCCP group reported more panic-type beliefs about chest pain (5.8 vs. 4.3, P < 0.05) and lower 'illness coherence' (a patient's belief that the illness 'makes sense') (3.5 vs. 4.7, P < 0.05). Anxiety and depression scores were similar in both groups. Both groups had similar levels of health-care use but patients with NCCP saw more types of health-care worker (mean 1.7) than those with CCP (mean 1.4, P < 0.05).

CONCLUSION

Patients with NCCP are as disabled and distressed as patients with CCP however current services fail to meet their needs. We suggest that a biopsychosocial approach should be explored.

Predictors of normal coronary arteries at coronary angiography

BACKGROUND

Coronary angiograms are important in the diagnostic workup of patients with suspected coronary artery disease. However, little is known about the clinical predictors of normal angiograms and whether this rate varies across different cardiac centers in Ontario.

METHODS

We conducted a study using the Cardiac Care Network Variations in Revascularization Practice in Ontario database of 2,718 patients undergoing an index cardiac catheterization for an indication of stable angina between April 2006 and March 2007 at one of 17 cardiac hospitals in Ontario. We determined predictors of normal coronary angiograms (0% coronary stenosis) and compared rates of patients with normal catheterizations across centers.

RESULTS

Overall, 41.9% of patients with stable angina had a normal catheterization. A multivariate model demonstrated female gender to be the strongest predictor of a normal angiogram (odds ratio 3.55, 95% CI 2.93-4.28). In addition, atypical ischemic symptoms or no symptoms, the absence of diabetes, hyperlipidemia, smoking history, peripheral vascular disease, and angiography performed at a nonteaching site were associated with higher rates of normal catheterization. The rate of normal angiograms studied varied from 18.4% to 76.9% across hospitals and was more common in community compared with academic settings (47.1% vs 35.4%, P < .001).

CONCLUSIONS

The absence of traditional cardiac risk factors, female gender, and lack of typical angina symptoms are all associated with a higher frequency of normal cardiac catheterizations. The wide variation in Ontario in the frequency of normal angiograms in patients with stable angina suggests that there are opportunities to improve patient case selection.

Up-beat UK: a programme of research into the relationship between coronary heart disease and depression in primary care patients

BACKGROUND

Coronary heart disease and depression are both common health problems and by 2020 will be the two leading causes of disability worldwide. Depression has been found to be more common in patients with coronary heart disease but the nature of this relationship is uncertain. In the United Kingdom general practitioners are now being remunerated for case-finding for depression in patients with coronary heart disease, however it is unclear how general practitioners should manage these patients. We aim to explore the relationship between coronary heart disease and depression in a primary care population and to develop an intervention for patients with coronary heart disease and depression.

METHODS/DESIGN

This programme of research will consist of 4 inter-related studies. A 4 year prospective cohort study of primary care patients with coronary heart disease will be conducted to explore the relationship between coronary heart disease and depression. Within this, a nested case-control biological study will investigate genetic and blood-biomarkers as predictors of depression in this sample. Two qualitative studies, one of patients' perspectives of treatments for coronary heart disease and co-morbid depression and one of primary care professionals' views on the management of patients with coronary heart disease and depression will inform the development of an intervention for this patient group. A feasibility study for a randomised controlled trial will then be conducted.

DISCUSSION

This study will provide information on the relationship between coronary heart disease and depression that will allow health services to determine the efficiency of case-finding for depression in this patient group. The results of the cohort study will also provide information on risk factors for depression. The study will provide evidence on the efficacy and feasibility of a joint patient and professional led intervention and data necessary to plan a definitive randomised controlled trial of the intervention.

[Predictive value of chest pain score for the diagnosis of acute coronary syndromes]

BACKGROUND AND OBJECTIVE

We analyzed the diagnostic utility of a chest pain score in patients evaluated for chest pain of possible coronary origin.

PATIENTS AND METHOD

We studied 1,068 consecutive patients coming to the emergency room with acute chest pain of possible coronary origin without ST-segment elevation, using a chest pain unit protocol. Chest pain was quantified by validated score (0-20 points). The diagnostic value of the chest pain score was analyzed for the diagnosis of acute myocardial infarction (AMI), unstable angina (UA) and acute coronary syndrome (ACS; AMI or UA).

RESULTS

The diagnosis of ACS was established in 651 patients (61%), AMI in 439 (41%) and UA in 212 (20%). In the multivariate analysis a chest pain score > or = 10 was an independent predictor of ACS (odds ratio [OR] = 2.9; 95% confidence interval [CI] 2.1-4; p = 0.0001), along with an age older than 70 years (OR = 2.6; 95% CI,1.8-3.7; p = 0.0001), male gender (OR = 2; 95% CI, 1.4-2.8; p = 0.0001); insulin-dependent diabetes (OR = 2.3; 95% CI, 1.2-4.6; p = 0.016); previous myocardial infarction (OR = 1.6; 95% CI, 1.1-2.4; p = 0.022), ST depression (OR = 9.3; 95% CI, 5.2-16.7; p = 0.0001) and T wave inversion (OR = 2.5; 95% CI, 1.4-4.3; p = 0.0001). The chest pain score was associated with the diagnosis of both AMI (OR = 1.4; 95% CI, 1.1-1.9; p < 0.02) and UA (OR = 2.8; 95% CI, 1.8-4.2; p < 0.0001).

CONCLUSIONS

The chest pain score allows independent information for the early diagnosis of patients coming to the emergency department with acute chest pain of possible coronary origin.

A simple score for predicting coronary artery disease in patients with chest pain

BACKGROUND

We have previously derived a chest pain score by comparing those with and without coronary artery disease on angiography, which was subsequently validated in patients attending coronary angiography.

AIM

To test the predictive validity of the score prospectively in a more varied out-patient population, and to determine whether it had predictive validity in addition to exercise testing.

DESIGN

Prospective clinical study.

METHODS

The score was applied to 405 out-patients with chest pain who subsequently underwent coronary angiography. Framingham risk analysis and exercise testing were performed in 155.

RESULTS

The score had a sensitivity of 91.4% and specificity of 28% for coronary artery disease, which was found in 31.8%, 51%, 63%, and 82% of those with scores of 0, 1, 2, and 3, respectively. Gender (p < 0.001), age (p < 0.001), and chest pain score (p = 0.009) independently predicted coronary artery disease on multivariate Poisson regression analysis. The chest pain score had additive predictive value with Framingham risk analysis and Duke's score.

DISCUSSION

This simple chest pain score can predict coronary anatomy with similar sensitivity to exercise testing, and can be used in conjunction with exercise testing and other measures. Further validation of the chest pain score in the primary care setting will be useful.

Bedside diagnosis of coronary artery disease: a systematic review

PURPOSE

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.

CONCLUSION

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.

Palpation for muscular tenderness in the anterior chest wall: an observer reliability study

OBJECTIVE

To asses the interobserver and intraobserver reliability (in terms of day-to-day and hour-to-hour reliability) of palpation for muscular tenderness in the anterior chest wall.

DESIGN

A repeated measures designs was used.

SETTING

Department of Nuclear Medicine, Odense University Hospital, Denmark.

PARTICIPANTS

Two experienced chiropractors examined 29 patients and 27 subjects in the interobserver part, and 1 of the 2 chiropractors examined 14 patients and 15 subjects in the intraobserver studies.

INTERVENTION

Palpation for muscular tenderness was done in 14 predetermined areas of the anterior chest wall with all subjects sitting. Each dimension was rated as absent or present for tenderness or pain for each location. All examinations were carried out according to a standard written procedure.

RESULTS

Based on a pooled analysis of data from palpation of the anterior chest wall, we found kappa values of 0.22 to 0.31 for the interobserver reliability. For the intraobserver reliability, we found kappa values of 0.21 to 0.28 for the day-to-day reliability and 0.44 to 0.49 for the hour-to-hour reliability.

CONCLUSION

Our results indicated great variations between experienced chiropractors palpating for intercostal tenderness or tenderness in the minor and major pectoral muscles in a population of patients with and without chest pain. This may hamper the ability of clinicians to diagnose and classify the musculoskeletal component of chest pain if based exclusively on palpation of the anterior chest wall.