Health Technology Assessment 2004; Vol 8: number 2
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J Mant,1* RJ McManus,1 RAL Oakes,1 BC Delaney,1 PM Barton,2 JJ Deeks,3 L Hammersley,1 RC Davies,4 MK Davies5 and FDR Hobbs1
1Department of Primary Care and General Practice, University of Birmingham, UK
2Health Economics Facility, University of Birmingham, UK
3Centre for Statistics in Medicine, Institute of Health Sciences, Oxford, UK
4Sandwell and West Birmingham NHS Trust, Sandwell General Hospital, West Bromwich, UK
5University Hospital Birmingham NHS Trust, Edgbaston, UK
Chest pain is a common symptom in primary care, and may reflect coronary heart disease (CHD), as either an acute coronary syndrome (ACS) or exertional angina. Recent national guidance has emphasised the importance of inpatient assessment for the former and rapid specialist assessment for the latter. However, chest pain is a common symptom that is due to CHD in only a minority of cases, and specialist and emergency services would become swamped if everyone with chest pain was referred.
Questions the review sought to answer were the following:
MEDLINE, EMBASE, CINAHL, the Cochrane Library and electronic abstracts of recent cardiological conferences were searched for articles about the diagnosis of chest pain between 1966 and October 1999. Researchers identified from the National Research Register were surveyed and reference lists of relevant papers were checked.
Studies were included if they involved
Studies were excluded if they were solely concerned with the prognostic value of the test, if they used a casecontrol design or if, in the evaluation of chronic chest pain, they included >20% of patients with known CHD.
Eligible papers were reviewed in duplicate. Data were extracted on inclusion criteria, sources of bias, patient demographics and test performance results. A third reviewer checked extracted data.
Likelihood ratios (LRs) were calculated for each study, and pooled LRs were generated with 95% confidence intervals (CIs).
A Monte Carlo simulation was performed evaluating different assessment strategies for suspected ACS, and a discrete event simulation for the evaluation of models for the assessment of suspected exertional angina.
No clinical features in isolation were useful in ruling in or excluding an ACS. The clinical features most helpful were pleuritic pain (LR+ 0.19, 95% CI 0.14 to 0.25) and pain on palpation (LR+ 0.23, 95% CI 0.08 to 0.30).
The presence of ST elevation was highly specific for MI, with LR+ 13.1 (95% CI 8.28 to 20.6). A completely normal ECG was reasonably useful at ruling out a myocardial infarction (LR+ 0.14 (95% CI 0.11 to 0.20). Black box studies of clinical interpretation of ECGs found very high LR+ (145 in the best quality study), but low sensitivity (LR 0.58).
Point of care testing with troponins was cost-effective. Pre-hospital thrombolysis on the basis of ambulance telemetry was more effective but more costly than thrombolysis performed in hospital.
Resting ECG features were not found to be very useful. Presence of Q-waves had LR+ 2.56 (95% CI 0.89 to 7.30). One study reported a high LR+ of 9.96 (95% CI 2.5838.5) for QRS notching.
Presence of ST depression had LR+ 2.79 (95% CI 2.53 to 3.07) for a 1 mm cutoff and 3.85 (95% CI 2.49 to 5.98) for a 2 mm cutoff. The LRs were 0.44 (95% CI 0.40 to 0.47) (1 mm) and 0.72 (95% CI 0.65 to 0.81) (2 mm). Other methods of interpreting the exercise ECG did not result in dramatic improvements in these results. The test performed better in men than women.
No true evaluative studies were identified. Weak evidence was found to suggest that these clinics might be associated with reduced admission to hospital of patients with non-cardiac pain, better recognition of ACS, earlier specialist assessment of exertional angina and earlier diagnosis of non-cardiac chest pain.
Relevant research questions include the following:
Mant J, McManus RJ, Oakes RAL, Delaney BC, Barton PM, Deeks JJ, et al. Systematic review and modelling of the investigation of acute and chronic chest pain presenting in primary care. Health Technol Assess 2004;8(2).
The NHS R&D Health Technology Assessment (HTA) Programme was set up in 1993 to ensure that high-quality research information on the costs, effectiveness and broader impact of health technologies is produced in the most efficient way for those who use, manage and provide care in the NHS.
The research reported in this monograph was commissioned by the HTA Programme on behalf of the National Institute for Clinical Excellence (NICE). Technology assessment reports are completed in a limited time to inform the appraisal and guidance development processes managed by NICE. The review brings together evidence on key aspects of the use of the technology concerned. However, appraisal and guidance produced by NICE are informed by a wide range of sources.
The research reported in this monograph was funded as project number 97/12/01.
Criteria for inclusion in the HTA monograph series
Reports are published in the HTA monograph series if (1) they have resulted from work commissioned for the HTA Programme, and (2) they are of a sufficiently high scientific quality as assessed by the referees and editors.
Reviews in Health Technology Assessment are termed systematic when the account of the search, appraisal and synthesis methods (to minimise biases and random errors) would, in theory, permit the replication of the review by others.
HTA Programme Director: Professor Tom Walley
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