Does the patient with chest pain have a coronary heart disease? Diagnostic value of single symptoms and signs – a meta-analysis

Aim To determine the diagnostic value of single symptoms and signs for coronary heart disease (CHD) in patients with chest pain. Methods Searches of two electronic databases (EMBASE 1980 to March 2008, PubMed 1970 to May 2009) and hand searching in seven journals were conducted. Eligible studies recruited patients presenting with acute or chronic chest pain. The target disease was CHD, with no restrictions regarding case definitions, eg, stable CHD, acute coronary syndrome (ACS), acute myocardial infarction (MI), or major cardiac event (MCE). Diagnostic tests of interest were items of medical history and physical examination. Bivariate random effects model was used to derive summary estimates of positive (pLR) and negative likelihood ratios (nLR). Results We included 172 studies providing data on the diagnostic value of 42 symptoms and signs. With respect to case definition of CHD, diagnostically most useful tests were history of CHD (pLR = 3.59), known MI (pLR = 3.21), typical angina (pLR = 2.35), history of diabetes mellitus (pLR = 2.16), exertional pain (pLR = 2.13), history of angina pectoris (nLR = 0.42), and male sex (nLR = 0.49) for diagnosing stable CHD; pain radiation to right arm/shoulder (pLR = 4.43) and palpitation (pLR = 0.47) for diagnosing MI; visceral pain (pLR = 2.05) for diagnosing ACS; and typical angina (pLR = 2.60) and pain reproducible by palpation (pLR = 0.13) for predicting MCE. Conclusions We comprehensively reported the accuracy of a broad spectrum of single symptoms and signs for diagnosing myocardial ischemia. Our results suggested that the accuracy of several symptoms and signs varied in the published studies according to the case definition of CHD