Level 2: Mid-level evidence

Specific elements of chest-pain history are associated with a patient’s likelihood of acute MI or acute coronary syndrome, based on a systematic review of observational studies (JAMA. 2005;294:2623-2629). Chest-pain factors found to increase the likelihood of acute MI include radiation to the right arm or shoulder (positive likelihood ratio [LR] 4.7), radiation to the left arm (LR 2.3), radiation to both arms or shoulders (LR 4.1), and chest pain worse than previous angina or similar to previous MI (LR 1.8). Chest pain associated with exertion (LR 2.4), diaphoresis (LR 2), nausea or vomiting (LR 1.9), and chest pain described as pressure (LR 1.3) were also associated with an increased likelihood of acute MI.

Chest-pain factors associated with a decreased likelihood of acute MI included pain described as pleuritic (LR 0.2), positional (LR 0.3), or sharp (LR 0.3); pain reproducible with palpation (LR 0.3); pain at an inframammary location (LR 0.8); and pain not associated with exertion (LR 0.8).