Health Technology Assessment 2004;Vol. 8: No. 2 Systematic review and modelling of the investigation of acute and chronic chest pain presenting in primary care J Mant, RJ McManus, RAL Oakes, BC Delaney, PM Barton, JJ Deeks, L Hammersley, RC Davies, MK Davies and FDR Hobbs February 2004 HTA Health Technology Assessment NHS R&D HTA Programme HTA How to obtain copies of this and other HTA Programme reports. An electronic version of this publication, in Adobe Acrobat format, is available for downloading free of charge for personal use from the HTA website (http://www.hta.ac.uk). A fully searchable CD-ROM is also available (see below). Printed copies of HTA monographs cost £20 each (post and packing free in the UK) to both public and private sector purchasers from our Despatch Agents. Non-UK purchasers will have to pay a small fee for post and packing. For European countries the cost is £2 per monograph and for the rest of the world £3 per monograph. 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Systematic review and modelling of the investigation of acute and chronic chest pain presenting in primary care 1* 1 1 1 J Mant, RJ McManus, RAL Oakes, BC Delaney, 2 3 1 PM Barton, JJ Deeks, L Hammersley, 4 5 1 RC Davies, MK Davies and FDR Hobbs 1 Department of Primary Care and General Practice, University of Birmingham, UK 2 Health Economics Facility, University of Birmingham, UK 3 Centre for Statistics in Medicine, Institute of Health Sciences, Oxford, UK 4 Sandwell and West Birmingham NHS Trust, Sandwell General Hospital, West Bromwich, UK 5 University Hospital Birmingham NHS Trust, Edgbaston, UK *Corresponding author Declared competing interests of authors:none Published February 2004 This report should be referenced as follows: Mant J, McManus RJ, Oakes RAL, Delaney BC, Barton PM, Deeks JJ, et al. Systematic review and modelling of the investigation of acute and chronic chest pain presenting in primary care. Health Technol Assess2004;8(2). 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Health Technology Assessment2004; Vol. 8: No. 2 Abstract Systematic review and modelling of the investigation of acute and chronic chest pain presenting in primary care J Mant,1* RJ McManus,1 RAL Oakes,1 BC Delaney,1 PM Barton,2 JJ Deeks,3 L Hammersley,1 RC Davies,4 MK Davies5 and FDR Hobbs1 1Department of Primary Care and General Practice, University of Birmingham, UK 2Health Economics Facility, University of Birmingham, UK 3Centre for Statistics in Medicine, Institute of Health Sciences, Oxford, UK 4Sandwell and West Birmingham NHS Trust, Sandwell General Hospital, West Bromwich, UK 5University Hospital Birmingham NHS Trust, Edgbaston, UK *Corresponding author Objectives: To ascertain the value of a range of care testing with troponins was cost-effective. Pre- methods – including clinical features, resting and hospital thrombolysis on the basis of ambulance exercise electrocardiography, and rapid access chest telemetry was more effective but more costly than if pain clinics (RACPCs) – used in the diagnosis and early performed in hospital. In cases of chronic chest pain, management of acute coronary syndrome (ACS), resting ECG features were not found to be very useful suspected acute myocardial infarction (MI), and (presence of Q-waves had LR+ 2.56). For an exercise exertional angina. ECG, ST depression performed only moderately well Data sources: MEDLINE, EMBASE, CINAHL, the (LR+ 2.79 for a 1 mm cutoff), although this did Cochrane Library and electronic abstracts of recent improve for a 2 mm cutoff (LR+ 3.85). Other methods cardiological conferences. of interpreting the exercise ECG did not result in Review methods: Searches identified studies that dramatic improvements in these results. Weak considered patients with acute chest pain with data on evidence was found to suggest that RACPCs may be the diagnostic value of clinical features or an associated with reduced admission to hospital of electrocardiogram (ECG); patients with chronic chest patients with non-cardiac pain, better recognition of pain with data on the diagnostic value of resting or ACS, earlier specialist assessment of exertional angina exercise ECG or the effect of a RACPC. Likelihood and earlier diagnosis of non-cardiac chest pain. In a ratios (LRs) were calculated for each study, and pooled simulation exercise of models of care for investigation LRs were generated with 95% confidence intervals. A of suspected exertional angina, RACPCs were Monte Carlo simulation was performed evaluating predicted to result in earlier diagnosis of both different assessment strategies for suspected ACS, and confirmed coronary heart disease (CHD) and non- a discrete event simulation evaluated models for the cardiac chest pain than models of care based around assessment of suspected exertional angina. open access exercise tests or routine cardiology Results: For acute chest pain, no clinical features in outpatients, but they were more expensive. The isolation were useful in ruling in or excluding an ACS, benefits of RACPCs disappeared if waiting times for although the most helpful clinical features were further investigation (e.g. angiography) were long pleuritic pain (LR+ 0.19) and pain on palpation (LR+ (6 months). 0.23). ST elevation was the most effective ECG feature Conclusions:Where an ACS is suspected, emergency for determining MI (with LR+ 13.1) and a completely referral is justified. ECG interpretation in acute chest normal ECG was reasonably useful at ruling this out pain can be highly specific for diagnosing MI. Point of (LR+ 0.14). Results from ‘black box’ studies of clinical care testing with troponins is cost-effective in the interpretation of ECGs found very high specificity, but triaging of patients with suspected ACS. Resting ECG low sensitivity. In the simulation exercise of and exercise ECG are of only limited value in the management strategies for suspected ACS, the point of diagnosis of CHD. The potential advantages of RACPCs iii © Queen’s Printer and Controller of HMSO 2004. All rights reserved. Abstract are lost if there are long waiting times for further determining the relative cost-effectiveness of rapid investigation. Recommendations for further research access chest pain clinics compared with other include the following: determining the most innovative models of care; investigating how rapid appropriate model of care to ensure accurate triaging access chest pain clinics should be managed; and of patients with suspected ACS; establishing the cost- establishing the long-term outcome of patients effectiveness of pre-hospital thrombolysis in rural areas; discharged from RACPCs. iv Health Technology Assessment2004; Vol. 8: No. 2 Contents List of abbreviations .................................. vii The evaluation of suspected exertional angina: resting ECG ................................... 34 Executive summary .................................... ix The evaluation of suspected exertional angina: exercise ECG ................................. 34 1 Background ................................................ 1 The evaluation of suspected exertional The evaluation of suspected ACS .............. 1 angina: RACPCs ......................................... 36 The evaluation of suspected exertional Simulation model for the evaluation angina ......................................................... 2 of suspected exertional angina .................. 38 Setting of investigation of suspected exertional angina ....................................... 2 5 Discussion ................................................... 55 Complexities of the topic areas .................. 3 The evaluation of suspected ACS .............. 55 The evaluation of suspected exertional 2 Research questions .................................... 5 angina ......................................................... 58 Aims ............................................................ 5 Objectives ................................................... 5 6 Conclusions ................................................ 65 Implications for healthcare ........................ 65 3 Review methods ......................................... 7 Recommendations for further research ..... 65 Definitions .................................................. 7 Systematic review methods ......................... 7 Acknowledgements .................................... 67 Acute chest pain model method (Monte Carlo simulation) ........................... 9 References .................................................. 69 Chronic chest pain model (discrete event simulation) .................................................. 16 Appendix 1 Search strategies .................... 79 4 Results of the review ................................. 25 Appendix 2 Details of studies included The evaluation of suspected ACS .............. 25 in the review ............................................... 83 The evaluation of suspected ACS: clinical signs and symptoms ....................... 26 Appendix 3 List of excluded papers The evaluation of suspected acute coronary and reasons for exclusion ........................... 141 syndrome: resting ECG .............................. 27 The evaluation of suspected ACS: black Health Technology Assessment reports box .............................................................. 27 published to date ....................................... 159 The evaluation of suspected ACS: second-order Monte Carlo simulation ....... 30 Health Technology Assessment The evaluation of suspected exertional Programme ................................................ 167 angina ......................................................... 33 v Health Technology Assessment2004; Vol. 8: No. 2 List of abbreviations A&E accident and emergency LR likelihood ratio ACS acute coronary syndrome MI myocardial infarction CABG coronary artery bypass graft MPI myocardial perfusion imaging CASS coronary artery surgery study NSF National Service Framework CHD coronary heart disease PMH previous medical history CI confidence interval POCT point of care test CK creatinine kinase PTCA percutaneous transluminal coronary angioplasty CKMB creatinine kinase MB sub-fraction CPOU chest pain observation unit QALY quality-adjusted life-year DES discrete event simulation QoL quality of life ECG electrocardiogram RACPC rapid access chest pain clinic ER emergency room RCT randomised controlled trial ETT exercise tolerance test TnT troponin T ICER incremental cost-effectiveness ratio ULN upper limit normal IU international unit WHO World Health Organization All abbreviations that have been used in this report are listed here unless the abbreviation is well known (e.g. NHS), or it has been used only once, or it is a non-standard abbreviation used only in figures/tables/appendices in which case the abbreviation is defined in the figure legend or at the end of the table. vii © Queen’s Printer and Controller of HMSO 2004. 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