Tips and tools to help refine your approach to chest pain

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doi:doi: 10.12788/jfp.0301

Applied Evidence

Tips and tools to help refine your approach to chest pain

J Fam Pract. 2021 November;70(9):420-430 | doi: 10.12788/jfp.0301

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References

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The HEART score is calculated based on 5 components:

History of chest pain (slightly [0], moderately [+1], or highly [+2]) suspicious for ACS)
EKG (normal [0], nonspecific ST changes [+1], significant ST deviations [+2])
Age (< 45 y [0], 45-64 y [+1], ≥ 65 y [+2])
Risk factors (none [0], 1 or 2 [+1], ≥ 3 or a history of atherosclerotic disease [+2])^a
Initial troponin assay, standard sensitivity (≤ normal [0], 1-3× normal [+1], > 3× normal [+2]).

For patients with a HEART score of 0-3 (ie, at low risk), the pooled positive predictive value of a MACE was determined to be 0.19 (95% CI, 0.14-0.24), and the negative predictive value was 0.99 (95% CI, 0.98-0.99)—making it an effective tool to rule out a MACE over the short term²⁶ (TABLE 3^4,26-28).

Because the HEART Score was published in 2008, multiple systematic reviews and meta-analyses have compared it to the TIMI (Thrombolysis in Myocardial Infarction) and GRACE (Global Registry of Acute Coronary Events) scores for predicting short-term (30-day to 6-week) MACE in ED patients.^27,28,33,34 These studies have all shown that the HEART score is relatively superior to the TIMI and GRACE tools.

Characteristics of these tools are summarized in TABLE 3.^4,26-28

Diamond Forrester classification (in ED and outpatient settings). This tool uses 3 criteria—substernal chest pain, pain that increases upon exertion or with stress, and pain relieved by nitroglycerin or rest—to classify chest pain as typical angina (all 3 criteria), atypical angina (2 criteria), or noncardiac chest pain (0 criteria or 1 criterion).²⁴ Pretest probability (ie, the likelihood of an outcome before noninvasive testing) of the pain being due to CAD can then be determined from the type of chest pain and the patient’s gender and age¹⁹ (TABLE 4¹⁹). Recent studies have found that the Diamond Forrester criteria might overestimate the probability of CAD.³⁵

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