Swap Clifford J, Nagurney John T
Massachusetts General Hospital, Boston, MA 02114, USA.
JAMA. 2005 Nov 23;294(20):2623-9. doi: 10.1001/jama.294.20.2623.
The chest pain history, physical examination, determination of coronary artery disease (CAD) risk factors, and the initial electrocardiogram compose the information immediately available to clinicians to help determine the probability of acute myocardial infarction (AMI) or acute coronary syndrome (ACS) in patients with chest pain. However, conflicting data exist about the usefulness of the chest pain history and which components are most useful.
To identify the elements of the chest pain history that may be most helpful to the clinician in identifying ACS in patients presenting with chest pain.
MEDLINE and Ovid were searched from 1970 to September 2005 by using specific key words and Medical Subject Heading terms. Reference lists of these articles and current cardiology textbooks were also consulted.
Certain chest pain characteristics decrease the likelihood of ACS or AMI, namely, pain that is stabbing, pleuritic, positional, or reproducible by palpation (likelihood ratios [LRs] 0.2-0.3). Conversely, chest pain that radiates to one shoulder or both shoulders or arms or is precipitated by exertion is associated with LRs (2.3-4.7) that increase the likelihood of ACS. The chest pain history itself has not proven to be a powerful enough predictive tool to obviate the need for at least some diagnostic testing. Combinations of elements of the chest pain history with other initially available information, such as a history of CAD, have identified certain groups that may be safe for discharge without further evaluation, but further study is needed before such a recommendation can be considered reasonable.
Although certain elements of the chest pain history are associated with increased or decreased likelihoods of a diagnosis of ACS or AMI, none of them alone or in combination identify a group of patients that can be safely discharged without further diagnostic testing.
胸痛病史、体格检查、冠状动脉疾病（CAD）危险因素的判定以及初始心电图构成了临床医生可立即获取的信息，以帮助确定胸痛患者发生急性心肌梗死（AMI）或急性冠状动脉综合征（ACS）的可能性。然而，关于胸痛病史的有用性以及哪些组成部分最有用，存在相互矛盾的数据。
确定胸痛病史中对临床医生识别胸痛患者的ACS可能最有帮助的要素。
通过使用特定关键词和医学主题词，检索了1970年至2005年9月的MEDLINE和Ovid数据库。还查阅了这些文章的参考文献列表和当前的心脏病学教科书。
某些胸痛特征降低了ACS或AMI的可能性，即刺痛、胸膜炎性、体位性或触诊可再现的疼痛（似然比[LRs]为0.2 - 0.3）。相反，放射至一侧肩部或双侧肩部或手臂的胸痛或由运动诱发的胸痛与增加ACS可能性的LRs（2.3 - 4.7）相关。胸痛病史本身尚未被证明是一种强大到足以避免至少进行一些诊断测试的预测工具。胸痛病史要素与其他初始可用信息（如CAD病史）的组合，已确定了某些可能无需进一步评估即可安全出院的群体，但在将此类建议视为合理之前，还需要进一步研究。
尽管胸痛病史的某些要素与ACS或AMI诊断的可能性增加或降低相关，但它们单独或组合起来都无法识别出一组无需进一步诊断测试即可安全出院的患者。
