Signs and symptoms in diagnosing acute myocardial, infarction and acute coronary syndrome: a diagnostic meta-analysis

Background Prompt diagnosis of acute myocardial infarction or acute coronary syndrome is very important. Aim A systematic review was conducted to determinate the accuracy of 10 important signs and symptoms in selected and non-selected patients. Design of study Diagnostic meta-analysis. Method Using MEDLINE, CINAHL, EMBASE, tracing references, and by contacting experts, studies that described one of the 10 signs and symptoms on one or both conditions were identified. Studies were excluded if they were not based on original data. Validity was assessed using QUADAS and all data were pooled using a random effects model. Results Sixteen of the 28 included studies were about patients who were non-selected. In this group, absence of chest-wall tenderness on palpation had a pooled sensitivity of 92% (95% confidence interval [CI] = 86 to 96) for acute myocardial infarction and 94% (95% Cl 91 to 96) for acute coronary syndrome. Oppressive pain followed with a pooled sensitivity of 60% (95% Cl = 55 to 66) for acute myocardial infarction. Sweating had the highest pooled positive likelihood ratio (LR+), namely 2.92 (95% Cl = 1.97 to 4.23) for acute myocardial infarction. The other pooled LR+ fluctuated between 1.05 and 1.49. Negative LRs (LR-) varied between 0.98 and 0.23. Absence of chest-wall tenderness on palpation had a LR- of 0.23 (95% Cl 0.18 to 0.29). Conclusion Based on this meta-analysis it was not possible to define an important role for signs and symptoms in the diagnosis of acute myocardial infarction or acute coronary syndrome. Only chest-wall tenderness on palpation largely ruled out acute myocardial infarction or acute coronary syndrome in low-prevalence settings.