The St.Emlyn’s Podcast

Chest pain that sounds like indigestion, feels mild or seems “atypical” can still be myocardial infarction. The difficult question is not whether troponin is useful, but which patients actually need testing — and how much weight we should give symptoms, cardiovascular risk factors and clinical judgement.

Professor Rick Body looks at the evidence behind those decisions, drawing on his own research and other studies of patients with suspected acute coronary syndromes. He explores which clinical features genuinely change the probability of myocardial infarction, which are less useful than we might think, and how to balance the risks of missing MI against unnecessary investigation.

In this podcast:

• Why “heavy” or “crushing” chest pain only modestly increased the probability of myocardial infarction in Rick’s study population.

• Why indigestion-like pain should not automatically reassure us, and why apparently “atypical” symptoms cannot safely exclude acute coronary syndrome.

• The diagnostic significance of associated features such as vomiting and, particularly, sweating observed by the clinician.

• Why dividing chest pain into “typical” and “atypical” presentations has limited discriminatory value.

• Why having no recognised hypertension, hyperlipidaemia, diabetes, smoking history or family history does not rule out acute myocardial infarction.

• How clinician gestalt does track with risk, but is not sufficiently reliable on its own to rule myocardial infarction in or out.

• Why none of this means testing everyone: Rick’s practical approach is to seek a convincing alternative explanation and use troponin when MI remains a plausible diagnosis that has not otherwise been adequately explained.

The numerical probabilities discussed come from populations already selected for investigation of suspected myocardial infarction, so they should not simply be transferred to every patient presenting with chest pain.

About Rick Body

Rick Body is Professor of Emergency Medicine at the University of Manchester and an Honorary Consultant in Emergency Medicine at Manchester University NHS Foundation Trust. His research has focused extensively on diagnostics in acute coronary syndromes, including cardiac troponin and strategies for the early rule-out of myocardial infarction.

Timestamps

00:00 – Which patients with chest pain need a troponin?
02:00 – What individual symptoms do to pre-test probability
05:00 – Vomiting and observed sweating
08:00 – The problem with “typical” and “atypical” symptoms
10:00 – Do traditional cardiovascular risk factors help?
13:00 – How reliable is clinical judgement or gestalt?
16:00 – Avoiding both under-investigation and over-investigation
17:00 – Rick’s practical approach to deciding when to test

Links and resources

The value of symptoms and signs in the emergent diagnosis of acute coronary syndromes

Examining the signs and symptoms experienced by individuals with suspected acute coronary syndrome in the Asia-Pacific region

‘Chest pain typicality’ in suspected acute coronary syndromes and the impact of clinical experience

Do risk factors for chronic coronary heart disease help diagnose acute myocardial infarction in the Emergency Department?

Can Emergency Physician Gestalt “Rule In” or “Rule Out” Acute Coronary Syndrome? Multicentre validation study

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