Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health

Chest pain accounts for approximately 6% of all emergency department (ED) visits and is the mostcommon reason for emergency hospital admission. One of the most serious diagnoses emergencyphysicians must consider is acute coronary syndrome (ACS). This is both common and serious,as ischemic heart disease remains the single biggest cause of death in the western world. Thehistory and physical examination are cornerstones of our diagnostic approach in this patient group.Their importance is emphasized in guidelines, but there is little evidence to support their supposedassociation. The purpose of this article was to summarize the findings of recent investigationsregarding the ability of various components of the history and physical examination to identify whichpatients presenting to the ED with chest pain require further investigation for possible ACS.

Previous studies have consistently identified a number of factors that increase the probabilityof ACS. These include radiation of the pain, aggravation of the pain by exertion, vomiting, anddiaphoresis. Traditional cardiac risk factors identified by the Framingham Heart Study are of limiteddiagnostic utility in the ED. Clinician gestalt has very low predictive ability, even in patients with anon-diagnostic electrocardiogram (ECG), and gestalt does not seem to be enhanced appreciably byclinical experience. The history and physical alone are unable to reduce a patient’s risk of ACS to agenerally acceptable level (<1%).

Ultimately, our review of the evidence clearly demonstrates that “atypical” symptoms cannot rule out ACS,while “typical” symptoms cannot rule it in. Therefore, if a patient has symptoms that are compatible withACS and an alternative cause cannot be identified, clinicians must strongly consider the need for furtherinvestigation with ECG and troponin measurement.