Coronary Risk Stratification of Chest Pain

Aka: Coronary Risk Stratification of Chest Pain, Likelihood of Coronary Disease as Cause of Chest Pain, CAD Pretest Probability in Chest Pain Presentation, Chest Pain Prediction Rules, Chest Pain Decision Rules

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II. Risk Factors

  1. See Cardiac Risk Factors
  2. See Framingham Score

III. Epidemiology: CAD Pretest Probability in Chest Pain Presentations

  1. Age 40 to 49 years
    1. Male: 69% risk CAD if typical Chest Pain, 38% if Atypical Chest Pain, 25% nonanginal Chest Pain
    2. Female: 37% risk CAD if typical Chest Pain, 14% if Atypical Chest Pain, 8% nonanginal Chest Pain
  2. Age 50 to 69 years
    1. Male: 77% risk CAD if typical Chest Pain, 49% if Atypical Chest Pain, 34% nonanginal Chest Pain
    2. Female: 47% risk CAD if typical Chest Pain, 20% if Atypical Chest Pain, 12% nonanginal Chest Pain
  3. Age 60 to 69 years
    1. Male: 84% risk CAD if typical Chest Pain, 59% if Atypical Chest Pain, 44% nonanginal Chest Pain
    2. Female: 58% risk CAD if typical Chest Pain, 28% if Atypical Chest Pain, 17% nonanginal Chest Pain
  4. Age 70 to 79 years
    1. Male: 89% risk CAD if typical Chest Pain, 69% if Atypical Chest Pain, 54% nonanginal Chest Pain
    2. Female: 68% risk CAD if typical Chest Pain, 37% if Atypical Chest Pain, 24% nonanginal Chest Pain
  5. Age >80 years
    1. Male: 93% risk CAD if typical Chest Pain, 77% if Atypical Chest Pain, 65% nonanginal Chest Pain
    2. Female: 76% risk CAD if typical Chest Pain, 47% if Atypical Chest Pain, 32% nonanginal Chest Pain
  6. References
    1. Bittencourt (2016) Circulation 134(3): 201-11 [PubMed]

IV. Diagnosis: Prediction Rules

  1. Preferred tests in Low Risk Chest Pain risk stratification
    1. HEART Score (more subjective than EDACS or T-Macs)
    2. Emergency Department Assessment of Chest Pain Score (EDACS)
    3. Troponin-Only Manchester Acute Coronary Syndrome Decision Aid (T-Macs)
  2. Other Chest Pain Prediction Rules
    1. INTERCHEST Chest Pain Rule
    2. Marburg Heart Score
    3. TIMI Risk Score
    4. Bosner Chest Pain Decision Rule
    5. Diamond and Forrester Chest Pain Prediction Rule
    6. Goldman Criteria for ICU Chest Pain Admission
    7. GRACE Score
    8. Cardiac Risk in Diabetes Score
    9. Vancouver Chest Pain Rule

V. Criteria: High Likelihood

  1. Known Coronary Artery Disease history
  2. Typical Anginal symptoms
    1. Men over age 60
    2. Women over age 70
  3. Characteristic symptoms
    1. Chest Pain radiating to the right arm or Shoulder (LR+ 4.7)
    2. Chest Pain radiating to both arms strongly suggests MI (LR+ 4.1 to 7.1)
    3. Exertional Chest Pain (LR+ 2.4)
    4. Diaphoresis (LR 2.0)
    5. Nausea and Vomiting (LR 1.9)
  4. Pain worse than prior Angina pain or similar to prior Myocardial Infarction (LR 1.8)
  5. History of Variant Angina
  6. Chest Pain with acute Congestive Heart Failure signs
    1. New Mitral Regurgitation murmur
    2. Hypotension
    3. Pulmonary Rales
    4. New S3 Gallop rhythm
    5. New Jugular Venous Distention
  7. EKG in Cardiac Ischemia
    1. Transient Electrocardiogram changes
      1. Associated with pain or hemodynamic changes
    2. ST Segment increase or decrease over 1 mm
    3. Deep symmetric T-wave inversion
      1. Occurs in multiple precordial leads

VI. Criteria: Intermediate Likelihood (high likelihood features absent)

  1. Typical Anginal symptoms
    1. Men under age 60
    2. Women under age 70
  2. Diabetes Mellitus and Chest Pain
  3. Cardiac Risk Factors (over 1) and Atypical Chest Pain
    1. Pleuritic Chest Pain
    2. Chest Pain primarily in lower or mid Abdomen
    3. Chest Pain localizable with one finger
    4. Reproducible Chest Pain
      1. Exacerbated by movement or palpation of chest wall
    5. Chest Pain is constant and lasts for days
    6. Chest Pain duration only for a few seconds
    7. Chest Pain radiates into legs
  4. Extra-cardiac vascular disease
  5. EKG in Cardiac Ischemia
    1. ST depression of 0.05-1mm
    2. T Wave Inversion of over 1 mm
      1. Occurs in leads with dominant R-waves

VII. Criteria: Low Likelihood

  1. Can often be discharged from ER with recheck with 72 hours
  2. Absence of Intermediate likelihood symptoms AND
    1. Age under 60 years old
    2. Atypical Chest Pain
      1. No radiation to arm, Shoulder, neck or jaw
      2. Reproducible Chest Pain on palpation (LR+ 0.3)
      3. Positional Chest Pain (LR 0.3)
      4. No pressure Sensation
        1. Pleuritic Chest Pain (LR+ 0.2)
        2. Sharp Chest Pain (LR+ 0.3)
    3. Only one Cardiac Risk Factor (not Diabetes Mellitus)
    4. Electrocardiogram normal
      1. T-waves flat or inversion of less than 1 mm
      2. Occurs in dominant R Waves leads

VIII. References

  1. Velasco, Lee, Chandra (2019) Crit Dec Emerg Med 33(1): 3-10

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