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Acute Coronary Syndrome: Sensitivity and Specificity

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

[Edit Diagnosis] [Merge dx] [Add prevalence]

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
500 10%
0%
More, Edit...

The sensitivity and specificity of findings for Acute Coronary Syndrome are listed below. See the left navigation bar to change the display.

Blood Test

Finding SensitivitySpecificity Comments, Study
CK-MB Subforms
Duplicate Edit		 91%89%

within first 6 hours

Study: Circulation 1999 Apr 6;99(13):1671-7. PMID 10190875
CK-MB Subforms
Duplicate Edit		 96%98%

at 10 hours

Study: Circulation 1999 Apr 6;99(13):1671-7. PMID 10190875
CK-MB Subforms
Duplicate Edit		 21.1%90.5%

at 2 hours

Study: Circulation 1999 Apr 6;99(13):1671-7. PMID 10190875
Myoglobin
Duplicate Edit		 78%89%

within first 6 hours

Study: Circulation 1999 Apr 6;99(13):1671-7. PMID 10190875
Myoglobin
Duplicate Edit		 26.3%87.3%

at 2 hours

Study: Circulation 1999 Apr 6;99(13):1671-7. PMID 10190875
Troponin I
Duplicate Edit		 92.3%94.6%

at 10 hours

Study: Circulation 1999 Apr 6;99(13):1671-7. PMID 10190875
Troponin I
Duplicate Edit		 57.5%94.3%

at 6 hours

Study: Circulation. 1999 Apr 6;99(13):1671-7. PMID: 10190875
Troponin I
Duplicate Edit		 15.8%96.8%

at 2 hours

Study: Circulation 1999 Apr 6;99(13):1671-7. PMID 10190875
Troponin T
Duplicate Edit		 87%93%

at 10 hours

Study: Circulation 1999 Apr 6;99(13):1671-7. PMID 10190875
Troponin T
Duplicate Edit		 61.7%96.1%

at 6 hours

Study: Circulation. 1999 Apr 6;99(13):1671-7. PMID: 10190875
Troponin T
Duplicate Edit		 10.5%98.4%

at 2 hours

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

Electronic Monitor

Finding SensitivitySpecificity Comments, Study
Continuous Electrocardiogram Edit 68%99%

continuous monitoring of ST segments

Study: Ann Emerg Med 1998 Jan;31(1):3-11. PMID 9437335
ECG Edit 32%91%

ischemic changes

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

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

T-Wave Inversion Edit 24%87%

Study: JAMA. 2015 Nov 10;314(18):1955-65 PMID: 26547467
Tachycardia Edit 3.2%98%

heart rate > 120

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

Endocrine

Finding SensitivitySpecificity Comments, Study
Crackles Edit 9.2%95%

or rales

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

History

Finding SensitivitySpecificity Comments, Study
Exertional Chest Pain Edit 35.3%85%

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
Pain Radiating to Shoulders or Arms Edit 11%96%

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

Imaging

Finding SensitivitySpecificity Comments, Study
Trans-Thoracic Echocardiography Edit 93%60%

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

Neoplasm

Finding SensitivitySpecificity Comments, Study
Crackles Edit 9.2%95%

or rales

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

Physical Exam

Finding SensitivitySpecificity Comments, Study
Crackles Edit 9.2%95%

or rales

Study: JAMA. 2015 Nov 10;314(18):1955-65 PMID: 26547467
Hypotension Edit 3.1%99%

Systolic < 100 mmHg

Study: JAMA. 2015 Nov 10;314(18):1955-65 PMID: 26547467
No Chest Wall Tenderness Edit 91.7%27.8%

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
Tachycardia Edit 3.2%98%

heart rate > 120

Study: JAMA. 2015 Nov 10;314(18):1955-65 PMID: 26547467
Tachypnea Edit 10%95%

Study: JAMA. 2015 Nov 10;314(18):1955-65 PMID: 26547467
Tenderness to Palpation Edit 5.5%80%

pain reproduced on palpation

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

Vital Signs

Finding SensitivitySpecificity Comments, Study
Hypotension Edit 3.1%99%

Systolic < 100 mmHg

Study: JAMA. 2015 Nov 10;314(18):1955-65 PMID: 26547467
Tachycardia Edit 3.2%98%

heart rate > 120

Study: JAMA. 2015 Nov 10;314(18):1955-65 PMID: 26547467
Tachypnea Edit 10%95%

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

Untagged

Finding SensitivitySpecificity Comments, Study
Abnormal Prior Stress Test Edit 12%96%

Study: JAMA. 2015 Nov 10;314(18):1955-65 PMID: 26547467
HEART Score Edit No accuracy specified.

PLR = 13. threshold 7-10

Study: JAMA. 2015 Nov 10;314(18):1955-65 PMID: 26547467
History of Coronary Artery Disease Edit 41%79%

Study: JAMA. 2015 Nov 10;314(18):1955-65 PMID: 26547467
Peripheral Artery Disease Edit 7.5%97%

Study: JAMA. 2015 Nov 10;314(18):1955-65 PMID: 26547467
Sgarbossa Criteria Edit 37.2%96.6%

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
    ST Depression Edit 25%95%

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

     

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