Question 5Are the symptoms and description of the symptoms different in Black and Ethnic Minorities presenting with acute chest pain of suspected cardiac origin compared with Caucasians

Grading: 2+Well-conducted case–control or cohort studies with a low risk of confounding, bias or chance and a moderate probability that the relationship is causal
Johnson PA;Lee TH;Cook EF;Rouan GW;Goldman L;
Effect of race on the presentation and management of patients with acute chest pain.[see comment]
Ref ID 25397Ann Intern Medpgs: 593 to 6011993
Study TypeCohortFundingNot reported
Number of participantsFinal study population was 3031 after exclusions
Inclusion/Exclusion CriteriaInclusion: patients presenting to the emergency department with a chief complaint of anterior, percordial, or left lateral chest pain that could not be explained by obvious local trauma or abnormalities on a chest X ray. Patients that experienced cardiac arrest in the emergency department were excluded from the study. During the study period, 4173 potentially eligible patient visits occurred, and the final study population was 3031 after exclusions (11 due to incomplete data, 531 consent not obtained, 204 inadequate follow-up, 158 race not identified, and 238 as race was Asian or Hispanic).
Patient CharacteristicsOf 3031 patients included, 1374 (45%) were African American and 1657 (55%) were Caucasian with mean age of 53 years and 58 years, respectively (P < 0.001). The African American patients were significantly more likely to be female compared with Caucasian patients (68% versus 47%, respectively P < 0.0001), and less likely to have a past history of; coronary artery disease (30% versus 47%, respectively, P < 0.0001), cardiac catheterisation (6% versus 11%, respectively P < 0.0001), and coronary artery bypass surgery (3% versus 11%, respectively, P < 0.0001). African Americans compared with Caucasians were less likely to have a final diagnosis of acute MI (6% versus 12%, respectively, P < 0.0001), and this result is consistent given the prior history findings of African American patients versus Caucasian patients.
Recruitmentpatients presenting to the emergency department with a chief complaint of anterior, percordial, or left lateral chest pain that could not be explained by obvious local trauma or abnormalities on a chest X ray.
SettingEmergency department USA, Dec 1983 to Oct 1988
Interventions/Test/Factor being investigatedHistory, risk factors and signs and symptoms
ComparisonsAfrican Americans versus Caucasians with suspected acute MI
Length of Study/Follow-upNot applicable
Outcome measures studiedHistory, risk factors and signs and symptoms
ResultsAfrican American patients with a final diagnosis of acute Ml had similar presenting signs and symptoms compared with the Caucasian patients. Comparing the two racial groups clinical characteristics of acute M I, the odds ratios were all greater than 1.0 for chest pain greater than or equal to 30 min, pressure type chest pain, radiation of pain to left arm, left shoulder, neck or jaw, diaphoresis and rales on physical examination for both racial groups but these were not statistically different between the groups. While it was found that African American patients were less likely to have a final diagnosis of acute MI (P < 0.0001), there was no longer a statistical association with race and acute MI after adjustments for were made for presenting signs and symptoms using logistical regression analysis. The odds ratio for acute MI outcomes for African Americans compared with Caucasians was 0.77 (95% CI 0.54 to 1.1).
Safety and adverse effectsNot applicable
Does the study answer the question?Yes, African Americans had a similar clinical presentation of acute MI compared with Caucasians
Effect due to factor in study?Yes
Consistency of results with other studies?Consistent
Directly applicable to guideline population?Acute chest pain population therefore directly applicable
Internal ValidityAdequately addressed
Klingler D;Green WR;Nerenz D;Havstad S;Rosman HS;Cetner L;Shah S;Wimbush F;Borzak S;
Perceptions of chest pain differ by race
Ref ID 10300Am Heart Jpgs: 51 to 592002
Study TypeCohortFundingNational Institute of Aging, the National Institute of Nursing Research and the Office of Minority Health of the NIH
Number of participants215 in total, 157 African American, 58 white
Inclusion/Exclusion CriteriaPatients admitted with suspected acute MI. Patients were included if English was their primary language and they could recall pre-hospital events. Patients were excluded if they were of a race other than African American or Caucasian, were aged < 18 years, had known mental impairment, were pregnant, had a MI subsequent to admission, had a previous interview prior to admission, or had significant emergency data missing from their medical records.
Patient CharacteristicsMean age - 59±14 years African American, 62±15 years white (P=0.13)
Male – 46% African American, 57% white (P=0.15)
RecruitmentPatients who were admitted with acute MI between April 1999 and August 1999 to the ED chest pain unit
SettingSecondary care, USA
Interventions/Test/Factor being investigatedComparison of Medical history and risk factors between African American and white patients with acute MI
ComparisonsMedical history and risk factors of African American and white patients
Length of Study/Follow-upNot reported
Outcome measures studiedMedical history and risk factors
ResultsCharacteristics:
Mean age - 59±14 years African American, 62±15 years white (P=0.13)
Male – 46% African American, 57% white (P=0.15)
Diabetes – 28% African American, 16% white (P=0.05)
Hypertension – 67% African American, 55% white (P=0.12)
Hypercholesterolemia – 28% African American, 34% white (P=0.5)
Angina – 8% African American, 3% white (P=0.37)
Heart attack – 27% African American, 16% white (P=0.06)
Congestive heart failure – 12% African American, 12% white (P=0.99)
Coronary angiography – 15% African American, 10% white (P=0.4)
Coronary artery bypass graph – 8% African American, 21% white (P=0.01)
Smoker – 29% African American, 31% white (P=0.74)
Prior stomach complaints – 16% African American, 29% white (P=0.03)

Symptoms:
Cardiac
Chest pain – 78% African American, 79% white (P=0.88)
Chest pressure – 62% African American, 76% white (P=0.06)
Chest tightness – 51% African American, 58% white (P=0.37)
Chest discomfort – 64% African American, 59% white (P=0.5)
Palpitations – 40% African American, 26% white (P=0.07)
Any of the above – 97% African American, 93% white (P=0.16)
Gastrointestinal
Stomach pain – 22% African American, 17% white (P=0.47)
Heartburn – 26% African American, 21% white (P=0.41)
Indigestion – 26% African American, 22% white (P=0.58)
Gas pain – 33% African American, 28% white (P=0.49)
Stomach problem – 22% African American, 19% white (P=0.59)
Any of the above – 57% African American, 59% white (P=0.86)
Associated symptoms
Nausea/vomiting – 44% African American, 41% white (P=0.74)
Arm/shoulder pain – 41% African American, 38% white (P=0.68)
Back pain – 30% African American, 33% white (P=0.69)
Jaw pain – 12% African American, 12% white (P=0.9)
Headache – 37% African American, 29% white (P=0.29)
Neck pain – 29% African American, 28% white (P=0.86)
Numbness/tingling – 33% African American, 32% white (P=0.96)
Shortness of breath – 62% African American, 60% white (P=0.85)
Cough – 38% African American, 26% white (P=0.09)
Dizziness – 54% African American, 48% white (P=0.5)
Sweating – 50% African American, 53% white (P=0.68)
Weakness/fatigue – 68% African American, 60% white (P=0.29)

There was no significant difference in the one worst reported symptom (respiratory, cardiac, gastrointestinal, other, unable to identify) between African American and white patients. There was also no significant difference in the location of pain (above diaphragm, below diaphragm, both, other), the timing of the pain (constant, intermittent, wax/wane) and the median discomfort and control of pain between African American and white patients.
Safety and adverse effectsNot applicable
Does the study answer the question?Patients were interviewed from April 1999 to August 1999. Patients were identified through a floor census and screened through a brief review of their medical charts. Patients were approached to participate based on their medical record number. 215 met the inclusion criteria out of 588 who were approached.
A structured questionnaire was developed to assess the contextual, emotional and behavioural factors in patients seeking medical help. The questionnaire was adapted from existing questionnaires, after external validation by a group of experts it was piloted on 10 patients and altered accordingly.

Demographics and medical history:
27% were white and 73% were African American, there were no significant differences between the two groups' age, sex and insurance status (suggestive of socioeconomic status).
African Americans were significantly more likely to have diabetes (P=0.05) and to be taking calcium-channel blockers (P=0.005), however white patients were more likely to have had coronary artery bypass surgery (P=0.01) and to have had a previous stomach complaint (P=0.03).

Symptoms at presentation:
Those who were diagnosis as not having an MI were more likely to have had stomach pain (P=0.03) and sweating (P=0.05) at presentation. No significant differences were found between African American and white patients in the objective symptoms. There was no significant difference in the one worst reported symptom (respiratory, cardiac, gastrointestinal, other, unable to identify) between African American and white patients. There was also no significant difference in the location of pain (above diaphragm, below diaphragm, both, other), the timing of the pain (constant, intermittent, wax/wane) and the median discomfort and control of pain between African American and white patients.

African Americans were as likely as Caucasian patients to report typical objective symptoms but were marginally more likely to attribute their symptoms to a gastrointestinal source rather than a cardiac source (P = 0.05). Of 157 Caucasian patients, 11 patients were diagnosed as having had an MI (11%), while 27 out of 58 Caucasian patients (47%) were diagnosed with acute MI (P < 0.001). However of those patients with a final diagnosis of MI, 61% of African Americans attributed their symptoms to a gastrointestinal source and 11% to a cardiac source versus 26% and 33%, respectively for Caucasian patients.
Effect due to factor in study?Yes
Consistency of results with other studies?Consistent
Directly applicable to guideline population?Acute chest pain population therefore directly applicable
Internal ValidityNot addressed
Maynard C;Beshansky JR;Griffith JL;Selker HP;
Causes of chest pain and symptoms suggestive of acute cardiac ischemia in African-American patients presenting to the emergency department: a multicenter study
Ref ID 1424Journal of the National Medical Associationpgs: 665 to 6711997
Study TypeCohortFundingAgency for Health Care Policy and Research
Number of participants10001, of which 3401 (34%) were African Americans,, 6600 were white
Inclusion/Exclusion CriteriaIncluded: aged greater or equal to 30 years presenting with chest or left arm pain, shortness of breath, or other symptoms suggestive of acute cardiac ischemia from 10 participating hospitals in east and midwest USA. Excluded: patients with chest pain/discomfort related to trauma, surgical emergencies, those with a clear non-cardiac cause, patients transferred from other hospitals
Patient CharacteristicsIn the male group, the average age for African American patients was 52±14 years and 60±15 year for white patients (P<0.0001). The average time from symptom onset to emergency department arrival was 3 hours for African American patients and 2 hours for white patients (P=0.0006). 33% of African American men and 15% of white men were uninsured, 23% of African American men and 6% of white men had Medicaid, 28% of African Americans men and 44% of white men had Medicare; for all P <0.0001 (measure of socio economic status).
In the female group, the average age for African American patients was 55±15 years and 65±16 year for white patients (P <0.0001). The average time from symptom onset to emergency department arrival was 3.3 hours for African American patients and 3 hours for white patients (P=0.045). 26% of African Americans women and 12% of white women were uninsured, 24% of African Americans and 8% of white women had Medicaid, 33% of African Americans women and 56% of white women had Medicare; for all P <0.0001 (measure of socio economic status).
RecruitmentPatients admitted to 10 hospitals in east and midwest USA
SettingSecondary care, USA
Interventions/Test/Factor being investigatedIf race is determinant in diagnosing acute MI or angina
ComparisonsAfrican Americans and white patients
Length of Study/Follow-upNot reported
Outcome measures studiedSigns and symptoms and risk factors to diagnose acute MI or angina
ResultsMedical History and Clinical Characteristics
Men
Ulcer – 16% African American, 16% white (P=0.74)
Hypertension – 57% African American, 44% white (P=<0.0001)
Angina – 29% African American, 42% white (P=<0.0001)
MI – 20% African American, 35% white (P=<0.0001)
Stroke – 9% African American, 8% white (P=0.47)
Diabetes – 20% African American, 20% white (P=0.88)
Current smoker – 56% African American, 30% white (P=<0.0001)
Cardiac medications – 47% African American, 59% white (P=<0.0001)
Chest pain – 77% African American, 75% white (P=0.20)
Chest pain as primary symptom – 69% African American, 70% white (P=0.49)
Shortness of breath – 62% African American, 51% white (P=<0.0001)
Abdominal pain – 20% African American, 12% white (P=<0.0001)
Nausea – 28% African American, 24% white (P=0.01)
Vomiting – 13% African American, 7% white (P=<0.0001)
Dizziness – 35% African American, 26% white (P=<0.0001)
Fainting – 6% African American, 7% white (P=0.32)
Rales – 19% African American, 20% white (P=0.14)
S3 sound – 4% African American, 3% white (P=0.013)
Congestive heart failure – 16% African American, 16% white (P=0.65)
Systolic blood pressure >160 – 21% African American, 23% white (P=0.29)
Diastolic blood pressure >90 – 36% African American, 28% white (P=<0.0001)

Women
Ulcer – 14% African American, 14% white (P=0.73)
Hypertension – 64% African American, 51% white (P=<0.0001)
Angina – 32% African American, 39% white (P=<0.0001)
MI – 18% African American, 26% white (P=<0.0001)
Stroke – 9% African American, 9% white (P=0.85)
Diabetes – 32% African American, 23% white (P=<0.0001)
Current smoker – 34% African American, 24% white (P=<0.0001)
Cardiac medications – 60% African American, 64% white (P=0.01)
Chest pain – 79% African American, 72% white (P=<0.0001)
Chest pain as primary symptom – 69% African American, 64% white (P=0.0002)
Shortness of breath – 61% African American, 55% white (P=<0.0001)
Abdominal pain – 17% African American, 13% white (P=<0.0001)
Nausea – 35% African American, 29% white (P=<0.0001)
Vomiting – 14% African American, 10% white (P=<0.0001)
Dizziness – 33% African American, 26% white (P=<0.0001)
Fainting – 5% African American, 7% white (P=0.001)
Rales – 19% African American, 25% white (P=<0.0001)
S3 sound – 3% African American, 3% white (P=0.74)
Congestive heart failure – 15% African American, 18% white (P=0.019)
Systolic blood pressure >160 – 28% African American, 28% white (P=0.45)
Diastolic blood pressure >90 – 34% African American, 23% white (P=<0.0001)
Safety and adverse effectsNot applicable
Does the study answer the question?The study found that there were differences in patients' medical history dependant upon racial background. African Americans were more likely to smoke and have hypertension compared with Caucasians, and African American women were more likely to have diabetes than Caucasian women. Caucasian patients were more likely to have a history of angina or MI and to take cardiac medications. There was no difference in the number of African Americans and Caucasian male patients who had chest pain as a primary symptom. There were a higher number of African American female patients than Caucasian female patients who had chest pain as a primary symptom. African American patients were more likely to report additional symptoms of shortness of breath, abdominal pain, nausea, vomiting and dizziness. African Americans were more likely to have a diastolic blood pressure of > 90mmHg when admitted to hospital compared to Caucasian patients, and the authors stated that this is consistent with the finding of more previous systemic hypertension in African Americans.

Acute MI and angina was less likely to be diagnosed in African American men compared with Caucasian men (acute MI; 6% versus 12%, respectively; angina 8% compared to 20%). Non cardiac diagnoses were confirmed in almost half of African American men compared with one third of Caucasian men. Similarly only 4% of African American women had a final diagnosis of acute MI compared with 8% in Caucasian women, and angina was diagnosed in 12% of African American women compared with 17% of Caucasian women. Non cardiac diagnoses were confirmed in almost half of African American women compared with 39% of Caucasian women.

Logistic regression in 74% of the patients examined the racial differences in the diagnoses, using the following variables; medical history, sociodemographic factors, signs and symptoms, and the hospital the patient was admitted to. African American patients compared to Caucasian patients were half as less likely to develop acute MI (odds ratio 0.54, 95% CI 0.41 to 0.68).
Effect due to factor in study?Yes
Consistency of results with other studies?Consistent
Directly applicable to guideline population?Patients with chest pain, left arm pain, shortness of breath or symptoms suggestive of acute cardiac ischeamia, directly applicable.
Internal ValidityNot addressed
Teoh M;Lalondrelle S;Roughton M;Grocott-Mason R;Dubrey SW;
Acute coronary syndromes and their presentation in Asian and Caucasian patients in Britain
Ref ID 25394Heartpgs: 183 to 1882007
Study TypeCohortFundingListed as none
Number of participants2905 patients, 604 (21%) were Asian and 2301 (79%) were Caucasian
Inclusion/Exclusion CriteriaConsecutive patients requiring hospital admission for ACS recruited by a senior cardiac nurse. Patients of races other than Asian or Caucasian were excluded
Patient CharacteristicsAsians mean age 60.6 (SD 12.7) years, Caucasians 68.9 (SD 13.9) years (P < 0.001), Asians 66% male, Caucasians 62%
RecruitmentConsecutive by nurse in emergency department
SettingEmergency department UK
Interventions/Test/Factor being investigatedSigns and symptoms, risk factors
ComparisonsAsians versus Caucasian
Length of Study/Follow-upNot applicable
Outcome measures studiedSigns and symptoms, risk factors
ResultsFrontal upper body discomfort was reported by 94% of Asian patients versus 89% of Caucasian patients (P < 0.001), while almost twice as many Asian patients reported pain on the rear of their body compared with Caucasian patients (46% versus 25%, respectively, P < 0.001). The character of the discomfort as described by the Asian patients was ‘weight’ (34%), followed by ‘squeeze’ (28%), and ‘ache’ (14%). For Caucasian patients the most common term was ‘weight’ (28%), followed by ‘ache’ (23%), and ‘squeeze’ (20%).

There was a small but statistically significant difference in the intensity of discomfort reported, with Asian patients reporting a median pain rating of 7.5 compared with 7.0 in Caucasian patients (P < 0.002). Twenty four percent of Asian patients rated their discomfort at the maximum value of 10 compared with 19% of Caucasian patients. A smaller percentage of Asian patients (6%) reported feeling no discomfort at presentation (silent MI) compared with Caucasian patients (13%) (P = 0.002). These patients were identified by a combination of symptoms, including fatigue, shortness of breath, collapse and resuscitation following cardiac arrest. Logistic regression analysis was performed to determine which factors contributed to patients reporting a silent episode, and the most significant factor was a patients diabetic status, they were more than twice as likely to report that they felt no pain during presentation compared with non-diabetics (odds ratio 2.08, 95% CI 1.56 to 2.76). Analysis showed that Caucasian patients (odds ratio 1.61, 95% CI 1.08 to 1.10) were also more likely to feel no discomfort compared with Asian patients. Analysis with age as a continuous variable was also associated with silent episode.
Safety and adverse effectsNot applicable
Does the study answer the question?Yes. Asian patients were younger, more likely to be diabetic and they tended to report greater intensity of pain over a greater area of the body, and more frequent discomfort over the rear of their upper thorax than Caucasian patients.
Effect due to factor in study?Yes
Consistency of results with other studies?Consistent
Directly applicable to guideline population?Acute chest pain population therefore directly applicable
Internal ValidityNot addressed
Grading: 2-Case–control or cohort studies with a high risk of confounding bias, or chance and a significant risk that the relationship is not causal*
Barakat K;Wells Z;Ramdhany S;Mills PG;Timmis AD;
Bangladeshi patients present with non-classic features of acute myocardial infarction and are treated less aggressively in east London, UK
Ref ID 10302Heartpgs: 276 to 2792003
Study TypeCohortFundingK.Barakat wass supported by an MRC Clinical Training Fellowship
Number of participants371 patients, of which 108 were Bangladeshi and 263 were white
Inclusion/Exclusion CriteriaPatients who were white or Bangladeshi with acute MI. Inclusion criteria was acute MI as defined by the presence of cardiac chest pain with ST elevation > 1 mm in two consecutive leads, Q wave development, and a creatine kinase rise greater than twice the upper limit of normal (400 IU/ml).
Patient CharacteristicsThe mean age was 63±12 years in the Bangladeshi group and 68 ±19years in the white group (P<0.0001). 87% of the Bangladeshi group were male compared to 70% of the white group (P0.002). 1/3 of the Bangladeshi patients were fluent in English
RecruitmentPatients admitted to Royal London Hospital, UK, acute MI between May 1998 and April 2001
SettingRoyal London Hospital, UK
Interventions/Test/Factor being investigatedBangladeshi patients compared to white patients with acute MI
ComparisonsBangladeshi patients compared to white patients
Length of Study/Follow-upNot reported
Outcome measures studiedRisk factors, symptoms
ResultsBaseline characteristics:
Age (years) – Bangladeshi 63±12; Whites 68±19 (P<0.0001)
Male sex – 87% Bangladeshi; 70% Whites (P=0.002)
Smoking – 71.3% Bangladeshi; 70.3% Whites (P=0.85)
Hypertension – 43.5% Bangladeshi; 38.4% Whites (P=0.36)
Diabetes – 50% Bangladeshi; 15.2% Whites (P<0.0001)
Family history of IHD – 13% Bangladeshi; 29.3% Whites (P=0.0005)
Previous acute MI – 28.7% Bangladeshi; 48% Whites (P=0.0014)

Nature of chest pain and interpretation of symptoms by racial group: (Bangladeshi n-32, Whites n=31)
Central pain – 40.6% Bangladeshi, 87.1% White (P=0.0006)
Left sided pain – 34.4% Bangladeshi, 3.2% White (P=0.0006)
Other pain – 25% Bangladeshi, 97% White (P=0.0006)
Typical character of pain – 25% Bangladeshi, 58.1% White (P=0.0132)
Non-classical character of pain – 75% Bangladeshi, 41.9% White (P=0.0132)
Interpreted as acute MI– 46.9% Bangladeshi, 45.2% White (P=0.99)
Interpreted as other– 53.1% Bangladeshi, 54.8% White (P=0.99)
Initial response of sought health care advice – 46.9% Bangladeshi, 25.8% White (P=0.20)
Initial response of sought family advice – 37.5% Bangladeshi, 61.3 White (P=0.20)
Initial response of other – 15.6% Bangladeshi, 12.9% White (P=0.20)
(typical character is: heaviness, tightness, weight, pressure, band-like, gripping; non-classical character is: sharp, stabbing, pinching, burning)

Multivariate analysis of the likelihood of Bangladeshi patients to present with typical central chest pain compared with white patients:
Crude – (OR 0.11; 95% CI 0.03 to 0.38; P=0.0006)
Adjustment for age and sex – (OR 0.10; 95% CI 0.03 to 0.39; P=0.0007)
Adjustment for age, sex and diabetes – (OR 0.12; 95% CI 0.03 to 0.49; P=0.0031)
Adjustment for age, sex, diabetes, hypertension, smoking, family history of IHD and hypercholesterolemia – (OR 0.11; 95% CI 0.02 to 0.58; P=0.0094)
Adjustment for age, sex, diabetes, hypertension, smoking, family history of IHD, hypercholesterolemia and proficiency in English – (OR 0.10; 95% CI 0.01 to 0.79; P=0.0285)

Multivariate analysis of the likelihood of Bangladeshi patients to present with typical cardiac chest pain compared with white patients:
Crude – (OR 0.25; 95% CI 0.09 to 0.74; P=0.0118)
Adjustment for age and sex – (OR 0.25; 95% CI 0.08 to 0.77; P=0.0154)
Adjustment for age, sex and diabetes – (OR 0.19; 95% CI 0.05 to 0.70; P=0.0124)
Adjustment for age, sex, diabetes, hypertension, smoking, family history of IHD and hypercholesterolemia – (OR 0.13; 95% CI 0.03 to 0.63; P=0.0116)
Adjustment for age, sex, diabetes, hypertension, smoking, family history of IHD, hypercholesterolemia and proficiency in English – (OR 0.05; 95% CI 0.004 to 0.46; P=0.0091)
Safety and adverse effectsNot applicable
Does the study answer the question?The baseline characteristics of the study showed that Bangladeshis were younger, more often male and diabetic, and more likely to report a previous acute MI than Whites. However Bangladeshis were less likely to report a family history of ischaemic heart disease than whites. 1/3 of the Bangladeshi patients were assessed to be fluent in English.

Bangladeshis were significantly less likely to report central chest pain (OR 0.11; 95% CI 0.03 to 0.38; P=0.0006) than whites. This significant difference remained after adjustment for difference in age, sex, risk factor profiles and fluency in English. Bangladeshis were also were more likely to offer non-classic descriptions (sharp, stabbing, pinching, burning) and less likely to report classic descriptions of the character of pain (heaviness, tightness, weight, pressure, band-like, gripping) (OR 0.25; 95% CI 0.09 to 0.74; P=0.0118). These differences persisted after adjustment for difference in age, sex, risk factor profiles and fluency in English.

The study concluded that Bangladeshi patients with an acute MI were more likely to present with atypical symptoms compared to white patients. The Authors stated that this may lead to slower triage in the emergency department and delay in treatment, this factor needs recognition by emergency department staff in order to reduce mortality rates in this high risk group.
Effect due to factor in study?Not certain- selected patients with chest pain, hence directness to question may be inappropriate as in that patients with atypical symptoms not necessary included
Consistency of results with other studies?Consistent
Directly applicable to guideline population?Selected patients with chest pain, hence directness to question may be inappropriate as in that patients with atypical symptoms not necessary included
Internal ValidityNot addressed

From: Appendix D, Clinical evidence extractions

Cover of Chest Pain of Recent Onset
Chest Pain of Recent Onset: Assessment and Diagnosis of Recent Onset Chest Pain or Discomfort of Suspected Cardiac Origin [Internet].
NICE Clinical Guidelines, No. 95.
National Clinical Guideline Centre for Acute and Chronic Conditions (UK).
Copyright © 2010, National Clinical Guideline Centre for Acute and Chronic Conditions.

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