Today we had the chance to hear about 4 challenging cases of chest pain "fresh" from IMS and SM resident clinic.
For references on chest pain in clinic, see our references from the discussion:
- JAMA Rational Clinical Exam: Is this Patient Having a Myocardial Infarction?
- **Not clinic-based studies! All hospital/ER-based.**
- NICE Clinical Guideline Reference Guide (nice concise format)
- AFP "Evaluation of Chest Pain in Primary Care Patients"
- This employs a risk prediction score developed in a (German) primary care population with a sensitivity of 87%, but you still have to use clinical judgment with scores like this.
- Dr. Fonarow would like people to keep the ACC/AHA Guidelines for UA/NSTEMI front and center in your mind.
Dr. Yang wanted to make sure everyone was aware of the classic Braunwald tables (click to enlarge):
I would add the following table (click to enlarge), which I refer to for estimation of pre-test probability of CAD. Bear in mind that this table overestimates risk (in primary care), because it is derived from patients who were initially referred for noninvasive testing (many from cardiology clinics) and underwent LHC.
-Pryor DB, Shaw L, McCants CB et al. (1993) Value of the history and physical in identifying patients at increased risk for coronary artery disease. Annals of Internal Medicine 118 (2): 81–90.
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