Proposed clinical scale for the diagnosis of acute coronary syndrome in patients with an inconclusive electrocardiogram and myocardial injury biomarkers. / Propuesta de una escala clínica para el diagnóstico de síndrome coronario agudo en pacientes con electrocardiograma y biomarcadores de lesión miocárdica no concluyentes.

RATIONALE: Acute coronary syndrome (ACS) requires improved diagnostic accuracy through useful, safe and easy-to-apply tools. OBJECTIVES: To obtain an assessment scale for the diagnosis of ACS in patients with chest pain and nondiagnostic electrocardiogram and troponin concentrations. METHODS: A prospective cohort study included 286 patients treated in the emergency department for chest pain, with normal electrocardiogram and troponin levels. Using multiple logistic regression, we obtained the independent predictors for the diagnosis of ACS. The assessment scale's discriminative power was assessed with the area under the ROC curve. RESULTS: The diagnosis of ACS was confirmed in 103 patients (36%). The final predictive model included 3 endpoints: a history of coronary artery disease, hyperlipidaemia and a score≥6 points on the Geleijnse scale. The area under the ROC curve for the final model was 0.90 (95% confidence interval [95% CI] 0.85-0.93). A threshold of 5 points achieved a sensitivity of 76.7% (95% CI 68-84), a specificity of 91.8% (95% CI 87-95), a positive likelihood ratio of 9.36 (95% CI 5.70-15.40), a negative likelihood ratio of 0.25 (95% CI 18.00-36.00) and an overall diagnostic accuracy of 86.4% (95% CI 82-90). The predictive model was superior to the Geleijnse scale alone. CONCLUSIONS: The final scale showed good discriminative capacity for diagnosing ACS and could therefore be of interest for identifying ACS in emergency departments. Nevertheless, the scale needs to be validated in larger multicentre studies.

Diagnostic validity of hand gestures in chest pain of coronary origin. / Validez diagnóstica del lenguaje de las manos en el dolor torácico de origen coronario.

OBJECTIVES: To determine the frequency of 3 hand gestures by patients with chest pain and determine the diagnostic validity of the gestures in acute coronary syndrome. PATIENTS AND METHODS: A prospective study was conducted on 383 adult patients treated for chest pain in an emergency department. We observed certain hand gestures, previously referred to in the medical literature as characteristic of coronary pain (gesture 1: a clenched fist held over the sternal area or Levine's sign; gesture 2: open hand located over the same area; gesture 3: both hands placed in the centre of the chest), as well as other gestures. We analysed their association with the coronary origin of the pain. RESULTS: We confirmed the coronary origin of the pain in 164 (43%) patients (ACS group). The other 219 patients (57%) did not have a coronary origin for the pain (nonACS group). Eighty-nine percent of the patients identified their pain with one of the 3 classical gestures. The most frequent gesture was number 2, both overall (59%) and by group (60% ACS group; 57.5% nonACS group). There was no significant association between the type of gesture and the final diagnosis (P=.172). The greater specificity corresponded to Levine's sign (90%), followed by other gestures (86%) and gesture 3 (81%). CONCLUSIONS: Although 89% of the patients expressed their chest pain with one of the 3 manual gestures classically associated with coronary pain, none achieved sufficient diagnostic accuracy to be used as indicative of this type of pain.