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Does This Patient With Chest Pain Have Acute Coronary Syndrome? The Rational Clinical Examination Systematic Review

Journal Club Summary


Fanaroff AC, et al. JAMA. 2015 Nov 10;314(18):1955-65 

Methodology Score: 4.5/5              
Usefulness Score: 3/5

This meta-analysis found that few clinical variables were strong predictors of ACS amongst ED patients presenting with acute chest pain: prior abnormal stress test (LR + 3.1), radiation to both arms (LR+ 2.6), ischemic ECG changes (LR +3.6), ST depression (LR+ 5.3); HEART and TIMI scores are not useful for low risk patients. Serial troponins were not evaluated but remain essential for ruling out ACS in patients with more than a very low pre-test probability.
By: Dr. Benjamin Simard


Epi lesson: 

For diagnostic tests, LR+ increases the post-test probability of a diagnosis and LR- decreases the post-test probability. LR values generally have this impact: a) large and conclusive (LR+ >10, LR- <0.1), b) moderate (LR+ 5 to10, LR- 0.1 to 0.2), c) small but important (LR+ 2 to 5, LR- 0.2 to 0.5), d) unimportant (LR+ 1 to 2, LR- 0.5 to 1). In emergency medicine, we are generally most interested in ruling out serious conditions and look for tests with very high sensitivity and very low LR-.

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