RECURRENT CHEST PAIN IN PATIENTS WITH A HISTORY OF ACUTE CORONARY SYNDROMES: ASSESSING THE GESTALT OF CANADIAN CARDIOLOGISTS

Abstract

The diagnosis of an acute coronary syndrome (ACS) depends on history, physical examination, biomarkers and electrocardiogram (ECG) findings. Previous studies have validated the importance of specific historical features in the diagnosis of an ACS. However, it is not known if chest pain identical in quality to a patient’s past ACS-related chest pain has diagnostic value. We sought to determine whether clinicians use this historical feature to aid in the diagnosis of ACS. Attendees at the 2014 Canadian Cardiovascular Congress were approached to complete a survey which asked them to score the importance of “identical chest pain quality” in the diagnosis of recurrent ACS using clinical vignettes without new ECG changes or biomarker elevation. A linear scale from 1 to 10 (low-to-high) was utilized to record the likelihood of recurrent ACS. The clinical vignettes varied for age, sex, presence of diabetes, remoteness of ACS and severity of coronary disease. Recent ACS was defined as an ACS event within the preceding year, and an elderly patient was defined as 80 years of age or older. Of the 80 respondents, the majority were cardiologists and trainees (90%), and 68% were males. Sex of survey respondents for all vignettes combined did not influence ACS diagnosis (p=0.680). Early-career clinicians (<5 years in practice) accounted for approximately half of responses (49%), and were more likely to diagnose ACS compared to experienced clinicians (≥5 years in practice) (p=0.004). Respondents were more likely to diagnose ACS in male patients than in female patients (p<0.001). In elderly patients, known multi-vessel disease increased the likelihood of ACS (p<0.001), however, older age alone did not reach statistical significance (p=0.098). Presence of diabetes, or recent ACS history did not correlate with ACS diagnosis (p=0.089, and p=0.680, respectively). Median scores for vignettes are summarized in Table 1. Regardless of patient characteristics, the recurrence of “identical chest pain quality” to the incident ACS is perceived as an important aspect of ACS diagnosis. However, more experienced cardiologists appear less reliant on this historical feature. ACS was diagnosed less frequently in women reporting “identical chest pain quality.” Responses for vignettes describing patients with the highest risk of atherosclerosis were varied, with underlying multi-vessel coronary artery disease, but not diabetes increasing the likelihood of an ACS diagnosis. Future studies are needed to determine the validity of this potential diagnostic predictor.