For medical students and doctors who want to use Venn diagrams, risk scores, the latest evidence and medical statistics to improve their history taking of patients with chest pain and improve their diagnosis of Acute Coronary Syndrome (ACS).

1. How to improve the teaching
of “Chest Pain”
Dr Jake Matthews
2021

2. How to diagnose a myocardial infarction?
• Patient with chest pain attends ED or GP:
• Observations
• ECG
• Classical symptoms and signs of ACS
• Troponins
• Risk score
• Imaging

3. A previous example that got me thinking…

4. Ways of learning medicine:
• Eminence = your Prof said heart attacks present with these symptoms… so
that’s what you believe
• Textbook = lists the classical signs, symptoms and investigations of a
particular disease (rote learning)
• Pathophysiological = this is how the disease works and so normally
produces these symptoms (first principles)
• Organ systems = pathophysiological with some organisation
• Symptom cluster = these groups of symptoms produce a list of differential
diseases including the one you want to learn about
• Patient presenting complaint = undifferentiated signs and symptoms that
have to be grouped into a list of differentials
• Scoring systems = The most common signs and symptoms of a disease

5. Is there a gold standard way to teach
medicine?
• The traditional approach = creates long lists of signs and symptoms
• Hard to remember them all
• Very little waiting of the relevance of important of the specific details
• The scoring approach =
• Based on limited evidence
• Normally either assumes good knowledge/ experience of the condition
already
• A limited number of signs or symptoms listed which may miss other
relevant details.

11. How to diagnose a myocardial infarction?
• Patient with chest pain attends ED or GP:
• Classical symptoms and signs of ACS
• What are the classical S&S?
• S&S with best PPV
• Most common S&S
• Most predictive points in the history
• Based on validated risk scores
• Differentiate the differentials

12. Chest Pain
Differentials for chest pain in the ED
https://journals.sagepub.com/doi/full/10.1177/2048872619885346
STEMI
NSTEMI
UA
Stable
Angina
Pericarditis
Myocarditis
HTN crisis
Takotsubo
syndrome
Tachycardia
HOCM
Aortic
stenosis
Pulmonary
Emboli
Cardiac
contusion
Pneumonia
Aortic
dissection
Peptic
Ulcer
Pneumothorax
GORD
Oesophageal
spasm
Asthma
Thoracic
Trauma
Rib
fracture
Cholecystitis
Pancreatitis
Anxiety
Psychogenic
Herprs
Zoster
MSKI
Non-specific chest pain
Tietze
syndrome
Arrhythmia
More dangerous
differentials

13. Chest Pain
Dynamic ST Changes >0.5mm during chest pain
New systolic murmur at ERB’s point
Summary of the Risk Scores – PPV Criteria for ACS in the
ED Higher PPV for ACS
Higher NPV for ACS
Lower PPV for ACS
New mitral regurg murmur
History
Symptoms
Signs
ECG
Biomarkers
Imaging
New LBBB or RBBB Ventricular tachycardia High degree atrioventricular block
HEART Score <3 (0)
GRACE risk score <140 (0)
Scoring
Radiation – neck/jaw /shoulder/ arm (8)
Chest discomfort (0)
Nausea (5)
Male (6)
Prior CVD/ CAD/ PVD/PCI/AMI/CABG (2)
Non specific ECG changes (1)
Age: Male >55 or Female >65 (2)
Physician suspects serious condition (1)
Absence of tenderness (1)
Exacerbated by exertion (1) Chest discomfort feels like pressure (1)
Patient assumes chest pain is cardiac (1)
Substernal pain (2) Chest pain >20 mins (1)
Known CAD Stenosis 50% (1)
Severe Angina (>2 episodes/24h) (1)
ASA use in 1/52 (1)
ECG ST changes >0.5mm (4)
Cardiac Arrest on admission (1)
Kilip Class (No CHF, JVD, Pulmonary oedema, Cardiogenic shock)
Normal observations (0)
Worse on inspiration (-4)
≥3 risk factors (4): dislipidaemia, diabetes, hypertension, current smoker, Fhx premature CAD,
Reproduced by palpation (-6)
Female (0)
Diaphoresis/ sweating/ perspiration (3)
hs-cTnT (Trop) (1)
Vomiting (1)
Hypotension SBP <100 (1)
Worsening/ Crescendo Angina (1)
HEART Score >7 (1)
CXR/ CTPA/ CTA/ USS
Reassuring

14. Chest Pain
The Oxford Handbook of Clinical
medicine diagnosis of Chest Pain
Higher PPV for ACS
Higher NPV for ACS
Lower PPV for ACS
The OHBCM
History
Symptoms
Signs
ECG
Biomarkers
Imaging
Chest discomfort
Sharp pain
>30 mins
Dull, crushing, pressure
Central
Sudden onset
Radiation to either arm/ neck or jaw
Radiation to back – Aortic dissection
Aggravating - Cold, emotion, exercise, large meals
Associated – nausea, SOB, sweating, dizzy
Diagnostic uncertainty
Scoring
Previous CVD, CABG, PCI
On cardiac medications
Age
Gender
FHx of IHD <55
Modified risk factors – smoking, diet, HTN, DM, obesity, sedentary lifestyle, high
chol, stress, cocaine, type A personality,
Levine sign , anxiety, pallor, tachycardia, hypotensive, signs of heart failure,
murmurs,
Pleuritic pain – catching breath – MSKI, pneumonia, PE
Associated – food, lying, hot drinks, alcohol – oesophageal spasm
Relieved by rest or GTN
Relieved by antacids
Relieved by leaning forwards – pericarditis
Palpitations
Syncope
SOB
Dizzy
ECG Changes CXR – consolidation, cardiomegaly, wide
mediastinum
Routine bloods and cardiac markers

15. Chest Pain
The Oxford Handbook of Acute
medicine diagnosis of STEMI
Higher PPV for ACS
Higher NPV for ACS
Lower PPV for ACS
The OHB Acute Medicine
History
Symptoms
Signs
ECG
Biomarkers
Imaging
Angina, longer, more severe, more intense
Not relieved by GTN
Dull, crushing, pressure
Central
Sudden onset
Radiation to either arm/ neck or jaw
Associated – nausea, vomiting, SOB, sweating, dizzy, distressed
Scoring
Previous CVD, CABG, PCI, LV failure
Age >70
hypotension
diabetes
Mitral regurg
Ventricular septal defect
Elderly, diabetic, women – may be silent
ECG Changes
CXR – consolidation, cardiomegaly, wide
mediastinum
Routine bloods and cardiac markers

16. Chest Pain
Dynamic ST Changes >0.5mm during chest pain
Hypotension
Pulmonary oedema
New systolic murmur at ERB’s point
Acute heart failure Kilip class >1
Prior PCI in 6/12
Prior CABG
ACCA High Risk Criteria for ACS in the
ED
Higher PPV for ACS
Higher NPV for ACS
Lower PPV for ACS
https://journals.sagepub.com/doi/full/10.1177/2048872619885346
New mitral regurg murmur
History
Symptoms
Signs
ECG
Biomarkers
Imaging
Chest pain >20 mins
New LBBB or RBBB
Ventricular tachycardia
High degree atrioventricular block
Elevated cardiac troponins
HEART Score >7
GRACE risk score >140
Scoring

17. Chest Pain
Retrosternal pain
Pressure/ Crushing
Radiation: jaw/left shoulder/arms
Exacerbation: exercise/cold/emotion
Perspiration
Nausea/vomiting
Well localized
Reproducible with palpation
Non-exertional
Nitrates reduces pain within mins
sharp
Levine Sign +ve (closed fist over the heart)
HEART Score Symptoms and signs
Higher PPV for ACS
Higher NPV for ACS
Lower PPV for ACS

18. Chest Pain
Radiation: right shoulder/arms (1)
hs-cTnT (Trop) (1)
Perspiration (1)
Vomiting (1)
Hypotension SBP <100 (1)
ECG +ve (1)
Worsening/ Crescendo Angina (1)
Troponin-only Manchester Acute Coronary
Syndromes (T-MACS) Decision Aid
Higher PPV for ACS
Higher NPV for ACS
Lower PPV for ACS
https://www.mdcalc.com/troponin-manchester-acute-coronary-syndromes-t-macs-decision-aid

19. Chest Pain
Radiation: Neck/ jaw/ shoulder/arms (5)
hs-cTnT (Trop) normal range
Worse on inspiration (-4)
Known coronary artery disease or ≥3 risk factors (4)
Prev. AMI/ CABG/ PCI
Risk factors: dislipidaemia, diabetes, hypertension,
current smoker, family history of premature CAD
Normal observations
ECG -ve
Reproduced by palpation (-6)
Emergency Department Assessment
of Chest Pain Score (EDACS) – Rule
Out
Higher PPV for ACS
Higher NPV for ACS
Lower PPV for ACS
https://www.mdcalc.com/emergency-department-assessment-chest-pain-score-edacs
Typical ACS chest pain – that has now stopped
Age 18-50
Female (0)
Male (6)
Diaphoresis/ sweating/ perspiration (3)

20. Chest Pain
HR 60-100 BPM
Abnormal cardiac enzymes
Cardiac Arrest on admission
Creatinine 62-115 umol/l
SBP 100-120
Age
ST Segment deviation on ECG
GRACE ACS Risk and Mortality
Calculator
Higher PPV for ACS
Higher NPV for ACS
Lower PPV for ACS
https://www.mdcalc.com/grace-acs-risk-mortality-calculator
Kilip Class (No CHF, JVD, Pulmonary oedema, Cardiogenic shock)

21. Chest Pain
HR 60-100 BPM
Abnormal cardiac enzymes (1)
Known CAD Stenosis 50% (1)
Severe Angina (>2 episodes/24h) (1)
ASA use in 1/52 (1)
Age >65 (1)
ECG ST changes >0.5mm (1)
TIMI Risk Score for UA/NSTEMI
Higher PPV for ACS
Higher NPV for ACS
Lower PPV for ACS
https://www.mdcalc.com/timi-risk-score-ua-nstemi
>3 CAD Risk factors = HTN, high Chol, diabetes, Fhx CAD,
current smoker (1)

22. Chest Pain
Absence of tenderness (1)
Exacerbated by exertion (1)
Substernal pain (2)
Prior CVD/PCI/AMI/CABG (2)
Gencer ACS score in GP
Higher PPV for ACS
Higher NPV for ACS
Lower PPV for ACS
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2832616/
Known CV risk factors >1 (2)
History
Symptoms
Signs
ECG
Biomarkers
Imaging
Chest pain >1-60 mins (1)
Male >55 or Female >65 (2)
Scoring

23. Chest Pain
Absence of tenderness (1)
Exacerbated by exertion (1)
Prior CVD/ CAD/ PVD/PCI/AMI/CABG (1)
Marburg Heart Score (MHS) ACS score
in GP
Higher PPV for ACS
Higher NPV for ACS
Lower PPV for ACS
https://www.mdcalc.com/marburg-heart-score-mhs
History
Symptoms
Signs
ECG
Biomarkers
Imaging
Patient assumes chest pain is cardiac (1)
Male >55 or Female >65 (1)
Scoring

24. Chest Pain
Absence of tenderness (1)
Exacerbated by exertion (1)
Prior CVD/ CAD/ PVD/PCI/AMI/CABG (1)
INTERCHEST Clinical Prediction Rule
for Chest Pain in Primary Care
Higher PPV for ACS
Higher NPV for ACS
Lower PPV for ACS
https://www.mdcalc.com/interchest-clinical-prediction-rule-chest-pain-primary-care
Physician suspects serious condition (1)
History
Symptoms
Signs
ECG
Biomarkers
Imaging
Chest discomfort feels like pressure (1)
Male >55 or Female >65 (1)
Scoring

25. Chest Pain
Nausea or sweating (1)
Prior CVD/ CAD/ PVD/PCI/AMI/CABG (1)
Grijseels rule for Chest Pain in
Primary Care
Higher PPV for ACS
Higher NPV for ACS
Lower PPV for ACS
https://watermark.silverchair.com/17-1-
History
Symptoms
Signs
ECG
Biomarkers
Imaging
Chest discomfort (0)
Male (1)
Scoring
Non specific ECG changes (1)
ST elevation ECG changes (4)
Radiation – neck/left arm (1)

26. Chest Pain
Nausea or sweating (5)
Prior CVD/ CAD/ PVD/PCI/AMI/CABG (2)
Bruins Slot rule for Chest Pain in
Primary Care
Higher PPV for ACS
Higher NPV for ACS
Lower PPV for ACS
https://academic.oup.com/fampra/article/28/3/323/484517
History
Symptoms
Signs
ECG
Biomarkers
Imaging
Chest discomfort (0)
Male (5)
Scoring
Radiation – neck/left arm (8)

27. Chest Pain
Dynamic ST Changes >0.5mm during chest pain
New systolic murmur at ERB’s point
Summary of the Risk Scores – PPV Criteria for ACS in the
ED Higher PPV for ACS
Higher NPV for ACS
Lower PPV for ACS
New mitral regurg murmur
History
Symptoms
Signs
ECG
Biomarkers
Imaging
New LBBB or RBBB Ventricular tachycardia High degree atrioventricular block
HEART Score <3 (0)
GRACE risk score <140 (0)
Scoring
Radiation – neck/jaw /shoulder/ arm (8)
Chest discomfort (0)
Nausea (5)
Male (6)
Prior CVD/ CAD/ PVD/PCI/AMI/CABG (2)
Non specific ECG changes (1)
Age: Male >55 or Female >65 (2)
Physician suspects serious condition (1)
Absence of tenderness (1)
Exacerbated by exertion (1) Chest discomfort feels like pressure (1)
Patient assumes chest pain is cardiac (1)
Substernal pain (2) Chest pain >20 mins (1)
Known CAD Stenosis 50% (1)
Severe Angina (>2 episodes/24h) (1)
ASA use in 1/52 (1)
ECG ST changes >0.5mm (4)
Cardiac Arrest on admission (1)
Kilip Class (No CHF, JVD, Pulmonary oedema, Cardiogenic shock)
Normal observations (0)
Worse on inspiration (-4)
≥3 risk factors (4): dislipidaemia, diabetes, hypertension, current smoker, Fhx premature CAD,
Reproduced by palpation (-6)
Female (0)
Diaphoresis/ sweating/ perspiration (3)
hs-cTnT (Trop) (1)
Vomiting (1)
Hypotension SBP <100 (1)
Worsening/ Crescendo Angina (1)
HEART Score >7 (1)
CXR/ CTPA/ CTA/ USS
Reassuring

28. There will be more to follow