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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

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

Blood Test

Finding +LR-LR Comments, Study
CK-MB Subforms
Duplicate Edit		 8.30.1

within first 6 hours

Study: Circulation 1999 Apr 6;99(13):1671-7. PMID 10190875
CK-MB Subforms
Duplicate Edit		 480

at 10 hours

Study: Circulation 1999 Apr 6;99(13):1671-7. PMID 10190875
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		 7.10.2

within first 6 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
Troponin I
Duplicate Edit		 17.10.1

at 10 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
Troponin I
Duplicate Edit		 4.90.9

at 2 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
Troponin T
Duplicate Edit		 15.80.4

at 6 hours

Study: Circulation. 1999 Apr 6;99(13):1671-7. PMID: 10190875
Troponin T
Duplicate Edit		 6.60.9

at 2 hours

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

Electronic Monitor

Finding +LR-LR Comments, Study
Continuous Electrocardiogram Edit 680.3

continuous monitoring of ST segments

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

T-Wave Inversion Edit 1.80.9

Study: JAMA. 2015 Nov 10;314(18):1955-65 PMID: 26547467
Tachycardia Edit 1.61

heart rate > 120

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

Endocrine

Finding +LR-LR Comments, Study
Crackles Edit 1.81

or rales

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

History

Finding +LR-LR Comments, Study
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
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

Imaging

Finding +LR-LR Comments, Study
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

Neoplasm

Finding +LR-LR Comments, Study
Crackles Edit 1.81

or rales

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

Physical Exam

Finding +LR-LR Comments, Study
Crackles Edit 1.81

or rales

Study: JAMA. 2015 Nov 10;314(18):1955-65 PMID: 26547467
Hypotension Edit 3.11

Systolic < 100 mmHg

Study: JAMA. 2015 Nov 10;314(18):1955-65 PMID: 26547467
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
Tachycardia Edit 1.61

heart rate > 120

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
Tenderness to Palpation Edit 0.31.2

pain reproduced on palpation

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

Vital Signs

Finding +LR-LR Comments, Study
Hypotension Edit 3.11

Systolic < 100 mmHg

Study: JAMA. 2015 Nov 10;314(18):1955-65 PMID: 26547467
Tachycardia Edit 1.61

heart rate > 120

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

Untagged

Finding +LR-LR Comments, Study
Abnormal Prior Stress Test Edit 30.9

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 20.7

Study: JAMA. 2015 Nov 10;314(18):1955-65 PMID: 26547467
Peripheral Artery Disease Edit 2.51

Study: JAMA. 2015 Nov 10;314(18):1955-65 PMID: 26547467
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
    ST Depression Edit 50.8

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

     

    The diagnosis database was created by Gavi Kohlberg and Mark Hammer. Copyright 2008-2014, All Rights Reserved. Disclaimer: This site is for health professionals and does not dispense medical advice. The content on this site is provided without warantee, expressed or implied, and without guarantee of accuracy. For questions, email info@getthediagnosis.org or click here.