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Good Positive and Negative Likelihood Ratios

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Acute Coronary Syndrome: Likelihood Ratios

Introduction: ACS is distinguished from stable angina by:

* Rest angina, which is usually more than 20 minutes in duration

* New onset angina that markedly limits physical activity

* Increasing angina that is more frequent, longer in duration, or occurs with less exertion than previous angina

ACS is divided into 3 major categories, namely unstable angina (defined by no serum marker elevation), NSTEMI (serum markers but no ST elevations), and STEMI.

STEMI (ST-segment Elevation Myocardial Infarction, aka ST-elevation MI) - Strict ECG definition: New ST elevation at the J-point in two contiguous leads with the cut-off points: >=0.2 mV in men or >=0.15 mV in women in leads V2-V3 and/or >=0.1 mV in other leads, in the absence of LVH and RBBB.

Cardiac Enzymes timecourse (sens/spec data) from Circulation PMID 10190875:

http://circ.ahajournals.org/cgi/content/full/99/13/1671/T2

Cardiac Enzymes timecourse, from UpToDate:

http://www.uptodate.com/online/content/image.do?imageKey=CARD%2F3187

Other clinical findings: JAMA. 2015 Nov 10;314(18):1955-65 PMID: 26547467 (old) JAMA. 1998 Oct 14;280(14):1256-63. PMID: 9786377

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Tags: Cardiac Problem Tag this Diagnosis.

Prevalence

Population / CalculatorPrevalence Comments / Study / Link
TIMI risk score 12% http://www.mdcalc.com/uanstemitimiscore

http://jama.ama-assn.org/cgi/content/abstract/284/7/835

patients presenting to the ED with chest pain, initially normal EKG and no history of unstable angina 9.1% Acad Emerg Med. 2002 Mar;9(3):203-8. PMID: 11874776
More, Edit...

The likelihood ratios of findings for Acute Coronary Syndrome are listed below. See the left navigation bar to change the display.

Good Positive and Negative Likelihood Ratios

Finding +LR-LR Comments, Study
CK-MB Subforms
Duplicate Edit
480

at 10 hours

Study: Circulation 1999 Apr 6;99(13):1671-7. PMID 10190875

Troponin I
Duplicate Edit
17.10.1

at 10 hours

Study: Circulation 1999 Apr 6;99(13):1671-7. PMID 10190875

Troponin T
Duplicate Edit
12.40.1

at 10 hours

Study: Circulation 1999 Apr 6;99(13):1671-7. PMID 10190875

CK-MB Subforms
Duplicate Edit
8.30.1

within first 6 hours

Study: Circulation 1999 Apr 6;99(13):1671-7. PMID 10190875

Trans-Thoracic Echocardiography Edit 2.30.1

by wall motion abnormalities

in this study PPV of WMA was 31% - specificity is low because of old WMAs

Study: Circulation. 1991 Sep;84(3 Suppl):I85-92. PMID: 1884510

Myoglobin
Duplicate Edit
7.10.2

within first 6 hours

Study: Circulation 1999 Apr 6;99(13):1671-7. PMID 10190875

Continuous Electrocardiogram Edit 680.3

continuous monitoring of ST segments

Study: Ann Emerg Med 1998 Jan;31(1):3-11. PMID 9437335

Troponin T
Duplicate Edit
15.80.4

at 6 hours

Study: Circulation. 1999 Apr 6;99(13):1671-7. PMID: 10190875

Troponin I
Duplicate Edit
10.10.5

at 6 hours

Study: Circulation. 1999 Apr 6;99(13):1671-7. PMID: 10190875

Good Negative Likelihood Ratio

Finding +LR-LR Comments, Study
No Chest Wall Tenderness Edit 1.30.3

patients presenting to the ED with chest pain, initially normal EKG and no history of unstable angina.

Study: Acad Emerg Med. 2002 Mar;9(3):203-8. PMID: 11874776

Good Positive Likelihood Ratio

Finding +LR-LR Comments, Study
Sgarbossa Criteria Edit 10.90.7

in patients with LBBB, Sgarbossa et al proposed the following ECG criteria for acute MI:

  • ST elevation >= 1mm concordant with QRS
  • ST depression >= 1mm in V1, V2, or V3
  • ST elevation >= 5mm discordant with QRS
  • In the HERO-2 trial, a positive ECG represented either of the first two criteria, with the last one dropped (previously they had used a scoring system).

    The numbers above are from HERO-2; note that replication in a community setting gave a sensitivity of only 10% with a specificity of 100%.

    Study: N Engl J Med. 1996 Feb 22;334(8):481-7. PMID: 8559200

    J Am Coll Cardiol. 2005 Jul 5;46(1):29-38. PMID: 15992631

    JAMA. 1999 Feb 24;281(8):714-9. PMID: 10052441

    Troponin T
    Duplicate Edit
    6.60.9

    at 2 hours

    Study: Circulation 1999 Apr 6;99(13):1671-7. PMID 10190875

    ST Depression Edit 50.8

    Study: JAMA. 2015 Nov 10;314(18):1955-65 PMID: 26547467

    Troponin I
    Duplicate Edit
    4.90.9

    at 2 hours

    Study: Circulation 1999 Apr 6;99(13):1671-7. PMID 10190875

    ECG Edit 3.60.7

    ischemic changes

    Study: JAMA. 2015 Nov 10;314(18):1955-65 PMID: 26547467

    Ann Emerg Med 1998 Jan;31(1):3-11. PMID 9437335

    Hypotension Edit 3.11

    Systolic < 100 mmHg

    Study: JAMA. 2015 Nov 10;314(18):1955-65 PMID: 26547467

    Abnormal Prior Stress Test Edit 30.9

    Study: JAMA. 2015 Nov 10;314(18):1955-65 PMID: 26547467

    Pain Radiating to Shoulders or Arms Edit 2.80.9

    radiating to both arms

    Study: JAMA. 2015 Nov 10;314(18):1955-65 PMID: 26547467

    Acad Emerg Med. 2002 Mar;9(3):203-8. PMID: 11874776

    Peripheral Artery Disease Edit 2.51

    Study: JAMA. 2015 Nov 10;314(18):1955-65 PMID: 26547467

    Exertional Chest Pain Edit 2.40.8

    patients presenting to the ED with chest pain, initially normal EKG and no history of unstable angina.

    Study: Acad Emerg Med. 2002 Mar;9(3):203-8. PMID: 11874776

    CK-MB Subforms
    Duplicate Edit
    2.20.9

    at 2 hours

    Study: Circulation 1999 Apr 6;99(13):1671-7. PMID 10190875

    Myoglobin
    Duplicate Edit
    2.10.8

    at 2 hours

    Study: Circulation 1999 Apr 6;99(13):1671-7. PMID 10190875

    History of Coronary Artery Disease Edit 20.7

    Study: JAMA. 2015 Nov 10;314(18):1955-65 PMID: 26547467

    Tachypnea Edit 20.9

    Study: JAMA. 2015 Nov 10;314(18):1955-65 PMID: 26547467

    Negative Findings

    Finding +LR-LR Comments, Study
    Tenderness to Palpation Edit 0.31.2

    pain reproduced on palpation

    Study: JAMA. 2015 Nov 10;314(18):1955-65 PMID: 26547467

    Poorly Diagnostic Findings

    Finding +LR-LR Comments, Study
    Tachycardia Edit 1.61

    heart rate > 120

    Study: JAMA. 2015 Nov 10;314(18):1955-65 PMID: 26547467

    Crackles Edit 1.81

    or rales

    Study: JAMA. 2015 Nov 10;314(18):1955-65 PMID: 26547467

    T-Wave Inversion Edit 1.80.9

    Study: JAMA. 2015 Nov 10;314(18):1955-65 PMID: 26547467

    Findings With Unspecified Accuracy

    Finding +LR-LR Comments, Study
    HEART Score Edit No accuracy specified.

    PLR = 13. threshold 7-10

    Study: JAMA. 2015 Nov 10;314(18):1955-65 PMID: 26547467