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Chest pain: if it hurts a lot, is heart attack more likely?

Body, Richard; Lewis, Philip S.; Carley, Simon; Burrows, Gillian; Haves, Bethany; Cook, Gary

European Journal of Emergency Medicine: April 2016 - Volume 23 - Issue 2 - p 89–94
doi: 10.1097/MEJ.0000000000000218

Background In previous studies including patients with suspected cardiac chest pain, those who had acute myocardial infarction (AMI) reported more severe chest pain than those without AMI. However, many patients with AMI present with very mild pain or discomfort. We aimed to investigate whether peak pain severity, as reported by patients in the Emergency Department, has any potential role in the risk stratification of patients with suspected cardiac chest pain.

Methods In this secondary analysis from a prospective diagnostic cohort study, we included patients presenting to the Emergency Department with suspected cardiac chest pain. Patients were asked to report their maximum pain severity using a 11-point numeric rating scale at the time of initial presentation. The primary outcome was a diagnosis of AMI, adjudicated by two independent investigators on the basis of reference standard (12 h) troponin testing.

Results Of the 455 patients included in this analysis, 79 (17.4%) had AMI. Patients with AMI had marginally higher pain scores (eight, interquartile range 5–8) than those without AMI (seven, interquartile range 6–8, P=0.03). However, the area under the receiver operating characteristic curve for the numeric rating scale pain score was 0.58 (95% confidence interval 0.51–0.65), indicating poor overall diagnostic accuracy. AMI occurred in 12.1% of patients with pain score 0–3, 17.1% with pain score 4–6 and 18.8% with pain score 7–10. Among patients with AMI, pain score was not correlated with 12-h troponin levels (r=−0.001, P=0.99).

Conclusion Pain score has limited diagnostic value for AMI. Scores should guide analgesia but shift the probability of AMI very little, and should not guide other clinical management.

aThe University of Manchester

bCentral Manchester University Hospitals Foundation NHS Trust, Manchester

cStockport NHS Foundation Trust, Stockport, UK

Correspondence to Richard Body, Emergency Medicine Research Office, Emergency Department, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK Tel: +44 161 276 5071; fax: +44 161 276 6925; e-mail:

Received May 29, 2014

Accepted September 9, 2014

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.