The chest pain history, physical examination, determination of coronary artery disease
(CAD) risk factors, and the initial electrocardiogram compose the information immediately
available to clinicians to help determine the probability of acute myocardial infarction
(AMI) or acute coronary syndrome (ACS) in patients with chest pain. However, conflicting
data exist about the usefulness of the chest pain history and which components are
To identify the elements of the chest pain history that may be most helpful to the
clinician in identifying ACS in patients presenting with chest pain.
MEDLINE and Ovid were searched from 1970 to September 2005 by using specific key words
and Medical Subject Heading terms. Reference lists of these articles and current cardiology
textbooks were also consulted.
Certain chest pain characteristics decrease the likelihood of ACS or AMI, namely,
pain that is stabbing, pleuritic, positional, or reproducible by palpation (likelihood
ratios [LRs] 0.2-0.3). Conversely, chest pain that radiates to one shoulder or both
shoulders or arms or is precipitated by exertion is associated with LRs (2.3-4.7)
that increase the likelihood of ACS. The chest pain history itself has not proven
to be a powerful enough predictive tool to obviate the need for at least some diagnostic
testing. Combinations of elements of the chest pain history with other initially available
information, such as a history of CAD, have identified certain groups that may be
safe for discharge without further evaluation, but further study is needed before
such a recommendation can be considered reasonable.
Although certain elements of the chest pain history are associated with increased
or decreased likelihoods of a diagnosis of ACS or AMI, none of them alone or in combination
identify a group of patients that can be safely discharged without further diagnostic