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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

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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 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

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

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