ST-segment depression on electrocardiography was helpful for ruling in ACS (LR+ = 5.3 95% CI, 2.1 to 8.6). The only significant physical examination finding was pain reproduced by palpation, which was helpful for ruling out ACS (negative likelihood ratio = 1.2 95% CI, 1.0 to 1.2). Additionally, patients with TIMI 3 before angioplasty. The difference between the mortality rate associated with grade 3 and the rate associated with grade 0 or 1 was significant (P 0.009). Significant symptoms included pain radiating to both arms (LR+ = 2.6 95% CI, 1.8 to 3.7), pain similar to prior ischemia (LR+ = 2.2 95% CI, 2 to 2.6), and change in pain pattern over the previous 24 hours (LR+ = 2.0 95% CI, 1.6 to 2.5). The mortality rate among patients with TIMI grade 2 flow was 7.4 percent, and the rate among those with TIMI grade 3 flow was 4.4 percent (P 0.08). Useful risk factors included a previous abnormal stress test result (LR+ = 3.1 95% CI, 2 to 4.7) and presence of peripheral arterial disease (LR+ = 2.7 95% CI, 1.5 to 4.8). Using only historical factors, the physician's overall clinical impression of definite ACS was moderately helpful for ruling in ACS (LR+ = 4.0 95% confidence interval, 2.5 to 6.6), but an impression of “definitely not” was not predictive. 1 The reference standard for diagnosis varied, but was commonly a discharge diagnosis of ACS or a cardiovascular event (cardiac death, myocardial infarction, or coronary revascularization) 14 to 42 days after presentation. A 2015 systematic review of 58 studies (N = 102,847) estimated the accuracy of individual factors in diagnosing ACS in patients of any age presenting to the emergency department with chest pain.
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