Diagnosing acute coronary syndrome in primary care: comparison of the physicians' risk estimation and a clinical decision rule

Fam Pract. 2011 Jun;28(3):323-8. doi: 10.1093/fampra/cmq116. Epub 2011 Jan 14.


Background: Diagnosing acute coronary syndrome (ACS) in a primary care setting poses a diagnostic dilemma for physicians.

Objective: We directly compared the diagnostic accuracy of a clinical decision rule (CDR) based on history taking and physical examination in suspected ACS with the risk estimates of the attending GP.

Methods: In a prospective multicenter study, patients suspected of ACS were included by the GP. GPs were asked to estimate the probability (0%-100%) of the presence of ACS. GPs collected patient data, but they were not aware of the CDR and did not score the patient accordingly.

Results: Two hundred and ninety-eight patients were included (52% female, mean age 66 years, 22% ACS). The area under the receiver operating characteristic (ROC) curve (AUC) was 0.75 [95% confidence interval (CI) 0.68-0.82] for the GP risk estimate and 0.66 (95% CI 0.58-0.73) for the CDR. There was an agreement between the risk estimation of the GP and a CDR in 51% and the prevalence of ACS in predefined low-, intermediate- and high-risk groups was similar for the GP and CDR estimates. In the low-risk group, according to the GP, four patients (8.2%) suffered an ACS. These four patients were all identified by the decision rule as high risk.

Conclusions: The GP classified patients as ACS or no ACS more adequately than the CDR, judged by the AUC. However, the use of a CDR in patients that are considered at low risk for ACS by the GP could reduce the amount of missed myocardial infarctions.

Publication types

  • Comparative Study
  • Multicenter Study
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Acute Coronary Syndrome / diagnosis*
  • Aged
  • Decision Support Techniques*
  • Female
  • Humans
  • Male
  • Middle Aged
  • Physicians, Primary Care*
  • Primary Health Care*
  • Prospective Studies
  • ROC Curve
  • Risk Assessment / methods*