Classical Presentation

The classic presenting symptom of ACS is chest pain, which is traditionally described as having a characteristic nature:

  • Heavy, aching or tight
  • Centre or left side of chest
  • Not related to respiration or movement
  • May radiate to one or both arms, neck or jaw

Likelihood ratios have been calculated that link features of the history with AMI [8-10].

Table of likelihood ratios

Table 1: Value of specific components of the chest pain history for the diagnosis of acute myocardial infarction
Historical factor Likelihood ratio
Ref 8 Ref 9 Ref 10
Increased likelihood of AMI:
Radiation to right arm/shoulder 4.7 2.9 2.6
Radiation to both arms/shoulders 4.1 7.1 4.1
Associated with exertion 2.4
Radiation to left arm 2.3 2.3 1.5
Associated with diaphoresis 2.0 2.0 2.1
Associated with nausea/vomiting 1.9 1.9 1.9
Worse than previous angina/similar to previous MI 1.8 1.3
Described as a pressure 1.3 1.4
Decreased likelihood of AMI:
Described as pleuritic 0.2 0.2 0.2
Described as positional 0.3 0.3 0.3
Described as sharp 0.3 0.3 0.3
Reproducible with palpation 0.3 0.2 – 0.4* 0.2
Inframammary location 0.8
Not associated with exertion 0.8

* In heterogenous studies, likelihood ratios are expressed as a range.

Learning Bite

No single factor in the history alone can confidently rule in or rule out AMI; characteristics of the pain with the highest likelihood for AMI are radiation of the pain to the right arm or shoulder, or to both arms or shoulders.