This article describes why most of the current methods taught to paramedics to identify ACS patients contradicts evidence that has been reported in the literature over the past 20 years. Areas where current teaching contradicts the evidence are highlighted, traditionally taught assessments which are non-diagnostic are identified, and those that are most diagnostic are listed and explained using a novel, evidence-based method to assess the patient’s history; the acronym RSVP3 (Radiation, Similarity, Variation, Pleuritic, Positional, Palpation) This acronym is meant to replace other commonly used, but non-diagnostically sensitive, acronyms such as OPQRST, DOLOR, SOCRATES and CHEST PAIN. Evidence to support this recommendations is given.
Nichols M, Peterson K, Alston L. 2014. Australian heart disease statistics. National Heart Foundation of Australia. Available at: https://heartfoundation.org.au/images/uploads/publications/HeartStats_2014_web.pdf
Australian Institute of Health and Welfare. 2014. Health-care expenditure on cardiovascular diseases 2008–2009. Available at:
Fineberg HV, Scadden D, Goldman L. Care of patients with a low probability of acute myocardial infarction. Cost effectiveness of alternatives to coronary-care-unit admission. N Engl J Med 1984;310:1301–7.
Keeley EC, Hillis LD. Primary PCI for myocardial infarction with ST-segment elevation. N Engl J Med 2007;356:47–54.
Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomized trials. Lancet 2003;361:13–20.
McNamara RL, Wang Y, Herrin J, et al. Effect of door-to-balloon time on mortality in patients with ST-segment elevation myocardial infarction. J Am Coll Cardiol 2006;47:2180–6.
Nallamothu B, Fox K, Kennelly B, De Werf F, Gore J, Steg P. Relationship of treatment delays and mortality in patients undergoing fibrinolysis and primary percutaneous coronary intervention. The Global Registry of Acute Coronary Events. Br Heart J 2006;93:1552–5.
Maguire BJ, O’Meara PF, Brightwell RF, O’Neill BJ, Fitzgerald GJ. Occupational injury risk among Australian paramedics: an analysis of national data. Med J Aust 2014;200:477–80. http://doi.org/10.5694/mja13.10941
Lee CP, Uk M, Medicine MI, et al. Advances Emergency physician estimates of the probability of acute coronary syndrome in a cohort of patients enrolled in a study of coronary computed tomographic angiography. CJEM 2012;14:147–56. http://doi.org/10.2310/8000.2012.110485
Cahan A, Gilon D, Manor O, et al. Clinical experience did not reduce the variance in physicians’ estimates of pretest probability in a cross-sectional survey. J Clin Epidemiol 2005;58:1211–6. doi:10.1016/j.jclinepi.2005.02.014.
Hess EP, Thiruganasambandamoorthy V, Wells G, et al. Diagnostic accuracy of clinical prediction rules to exclude acute coronary syndrome in the emergency department setting: a systematic review. CJEM 2008;10:373–82. doi:10.1016/j.jclinepi.2007.09.013
Fesmire FM, Martin EJ, Cao Y, Heath GW. Improving risk stratification in patients with chest pain: the Erlanger HEARTS3 score. Am J Emerg Med 2012;30:1829–37. http://doi.org/10.1016/j.ajem.2012.03.017
Than M, Flaws D, Cullen L, Deely JM. Cardiac risk stratification scoring systems for suspected acute coronary syndromes in the emergency department. Curr Emerg Hosp Med Reports 2013;1:53–63. http://doi.org/10.1007/s40138-012-0004-0
Than M, Herbert M, Flaws D, et al. What is an acceptable risk of major adverse cardiac event in chest pain patients soon after discharge from the emergency department. Int J Cardiol 2013;166:752–4. doi:10.1016/j.ijcard.2012.09.171.
Greene J. The perils of low-risk chest pain. Ann Emerg Med 2010;56:25A–8A.
Heberden W. Some account of a disorder of the breast. Medical Transactions 1772;2:59–67.
Eslick GD. Chest pain: a historical perspective. Int J Cardiol 2001;77:5–11.
Newberry L, Barnett GK, Ballard N. A new mnemonic for chest pain assessment. J Emerg Nurs 2005;31:84–5. http://doi.org/10.1016/j.jen.2004.10.005
Mitchell AM, Garvey JL, Chandra A, Diercks D, Pollack CV, Kline JA. Prospective multicenter study of quantitative pretest probability assessment to exclude acute coronary syndrome for patients evaluated in emergency department chest pain units. Ann Emerg Med 2006;47:447.
Høilund-Carlsen PF, Johansen A, Vach W, Christensen HW, Møldrup M, Haghfelt T. High probability of disease in angina pectoris patients: is clinical estimation reliable? Can J Cardiol 2007;23:641–7.
Panju AA, Hemmelgarn BR, Guyatt GH, Simel DL. The rational clinical examination: is this patient having a myocardial infarction? JAMA 1998;280:1256–63.22. Fanaroff AC, Rymer JA, Goldstein SA, Simel DL, Newby LK. Does this patient with chest pain have acute coronary syndrome? JAMA 2015;314:1955. http://doi.org/10.1001/jama.2015.12735
Body R, Carley S, Wibberley C, McDowell G, Ferguson J, Mackway-Jones K. The value of symptoms and signs in the emergent diagnosis of acute coronary syndromes. Resuscitation 2010;81:281–6. http://doi.org/10.1016/j.resuscitation.2009.11.014
Body R, Cook G, Burrows G, Carley S, Lewis PS. Can emergency physicians “rule in” and “rule out” acute myocardial infarction with clinical judgement? Emerg Med J 2014;31:872–6. http://doi.org/10.1136/emermed-2014-203832
Bruyninckx R, Aertgeerts B, Bruyninckx P, Buntinx F. Signs and symptoms in diagnosing acute myocardial infarction and acute coronary syndrome: a diagnostic meta-analysis. Br J Gen Pract 2008;58:105–11. http://doi.org/10.3399/bjgp08X277014
Grimes DA, Schulz KF. Refining clinical diagnosis with likelihood ratios. Lancet 2005;365:1500–5. http://doi.org/10.1016/S0140-6736(05)66422-7
Hayden SR, Brown MD. Likelihood ratio: a powerful tool for incorporating the results of a diagnostic test into clinical decision making. Ann Emerg Med 1999;33:575–80.
Han JH, Lindsell CJ, Hornung RW, et al. The elder patient with suspected acute coronary syndromes in the emergency department. Acad Emerg Med 2007;14:732–9. http://doi.org/10.1197/j.aem.2007.04.008
Walker NJ, Sites FD, Shofer FS, Hollander JE. Characteristics and outcomes of young adults who present to the emergency department with chest pain. Acad Emerg Med 2001;8:703–8.
Marsan RJ, Shaver KJ, Sease KL, Shofer FS, Sites FD, Hollander JE. Evaluation of a clinical decision rule for young adult patients with chest pain. Ibid. 2005;12:26–31.
Christenson J, Innes G, McKnight D, et al. A clinical prediction rule for early discharge of patients with chest pain. Ann Emerg Med 2006;47:1–10.
Jalili M, Hejripour Z, Honarmand AR, Pourtabatabaei N. Validation of the Vancouver chest pain rule: a prospective cohort study. Acad Emerg Med 2012;19:837–42.
Body R, McDowell G, Carley S, Mackway-Jones K. Do risk factors for chronic coronary heart disease help diagnose acute myocardial infarction in the emergency department? Resuscitation 2008;79:41–5. http://doi.org/10.1016/j.resuscitation.2008.06.009
Dooley J, Chang AM, Salhi R, Hollander JE. Relationship between body mass index and prognosis of patients presenting with potential acute coronary syndromes. Acad Emerg Med 2013;20:904–10. http://doi.org/10.1111/acem.12211
Henrikson CA, Howell EE, Bush DE, et al. Chest pain relief by nitroglycerin does not predict active coronary artery disease. Ann Intern Med 2003;139:979–86.
Shry EA, Dacus J, Van De Graaff E, Hjelkrem M, Stajduhar KC, Steinhubl SR. Usefulness of the response to sublingual nitroglycerin as a predictor of ischemic chest pain in the emergency department. Am J Cardiol 2002;90:1264–6.
Diercks DB, Boghos E, Guzman H, Amsterdam EA, Kirk JD. Changes in the numeric descriptive scale for pain after sublingual nitroglycerin do not predict cardiac etiology of chest pain. Ann Emerg Med 2005;45:581–5.
Grailey K, Glasziou PP. Diagnostic accuracy of nitroglycerine as a “test of treatment” for cardiac chest pain: a systematic review. Emerg Med J 2012;29:173–6. http://doi.org/10.1136/emj.2010.103994
Steele R, McNaughton T, McConahy M, Lam J. Chest pain in emergency department patients: if the pain is relieved by nitroglycerin, is it more likely to be cardiac chest pain? CJEM 2006;8:164–9.
Green GB, Hill PB. Chest pain: cardiac or not. In: Tintinalli J. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 2012, 7th edn. Sydney: McGraw-Hill.
Chun AA, McGee SR. Bedside diagnosis of coronary artery disease: a systematic review. Am J Med 2004;117:334–3.
Summers RL, Cooper GJ, Carlton FB, Andrews ME, Kolb JC. Prevalence of atypical chest pain descriptions in a population from the southern United States. Am J Med Sci 1999;318:142–5.
Canto JG, Shlipak MG, Rogers WJ, et al. Prevalence, clinical characteristics, and mortality among patients with myocardial infarction presenting without chest pain. JAMA 2000;283:3223–9.
Caracciolo EA, Chaitman BR, Forman SA, et al; Asymptomatic Cardiac Ischemia Pilot Investigators. Diabetics with coronary disease have a prevalence of asymptomatic ischemia during exercise treadmill testing and ambulatory ischemia monitoring similar to that of nondiabetic patients: an ACIP database study. Circulation 1996;93:2097–105.
Murray DP, O’Brien T, Mulrooney R, O’Sullivan DJ. Autonomic dysfunction and silent myocardial ischaemia on exercise testing in diabetes mellitus. Diabet Med 1990;7:580–4.
Richman PB, Brogan GX Jr, Nashed AN, Thode HC Jr. Clinical characteristics of diabetic vs nondiabetic patients who “rule-in” for acute myocardial infarction. Acad Emerg Med 1999;6:719–23.
Swap CJ. Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes. JAMA 2005;294:2623. http://doi.org/10.1001/jama.294.20.2623
Pelter MM, Riegel B, McKinley S, et al. Are there symptom differences in patients with coronary artery disease presenting to the ED ultimately diagnosed with or without ACS? Am J Emerg Med 2012;30:1822–8. http://doi.org/10.1016/j.ajem.2012.03.002
Rosen's Emergency Medicine: Concepts and Clinical Practice. Philadelphia, PA: Mosby/Elsevier; 2010.
Eriksson B, Vuorisalo D, Sylven C. Diagnostic potential of chest pain characteristics in coronary care. J Intern Med 1994;235:473–8.
Edwards M, Chang AM, Matsuura AC, Green M, Robey JM, Hollander JE. Relationship between pain severity and outcomes in patients presenting with potential acute coronary syndromes. Ann Emerg Med 2011;58:501–7. http://doi.org/10.1016/j.annemergmed.2011.05.036
Body R, Lewis PS, Carley S, Burrows G, Haves B, Cook G. Chest pain: if it hurts a lot, is heart attack more likely? Eur J Emerg Med 2016;23:89–94. http://doi.org/10.1097/MEJ.0000000000000218
Galinski M, Saget D, Ruscev M, et al. Chest pain in an out-of-hospital emergency setting: no relationship between pain severity and diagnosis of acute myocardial infarction. Pain Pract 2015;15:343–7. http://doi.org/10.1111/papr.12178
Johnson PA, Lee TH, Cook EF, Rouan GW, Goldman L. Effect of race on the presentation and management of patients with acute chest pain. Ann Intern Med 1993;118:593–601.
Skinner JS, Smeeth L, Kendall JM, Adams PC, Timmis A. NICE guidance. Chest pain of recent onset: assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin. Heart 2010;96:974–8. http://doi.org/10.1136/hrt.2009.190066
Goodacre S, Locker T, Campbell S. How useful are clinical features in the diagnosis of acute, undifferentiated chest pain? Acad Emerg Med 2002;9:203–8. http://doi.org/10.1197/aemj.9.3.203
Kamali A, Söderholm M, Ekelund U. What decides the suspicion of acute coronary syndrome in acute chest pain patients? BMC Emerg Med 2014;14:9. http://doi.org/10.1186/1471-227X-14-9
Berg J, Björck L, Dudas K, Lappas G, Rosengren A. Symptoms of a first acute myocardial infarction in women and men. Gend Med 2009;6:454–462. http://doi.org/10.1016/j.genm.2009.09.007
Coventry LL, Finn J, Bremner AP. Sex differences in symptom presentation in acute myocardial infarction: a systematic review and meta-analysis. Heart Lung 2011;40:477–91. http://doi.org/10.1016/j.hrtlng.2011.05.001
Available at: http://lifeinthefastlane.com/ecg-library/basics/pericarditis/ [Accessed 20 January 2016].
Marcus GM, Cohen J, Varosy PD, et al. The utility of gestures in patients with chest discomfort. Am J Med 2007;120:83–9. http://doi.org/10.1016/j.amjmed.2006.05.045
Lee TH, Goldman L: Evaluation of the patient with acute chest pain. N Engl J Med 2000;342:1187–95.
Goldman L, Kirtane AJ. Triage of patients with acute chest pain and possible cardiac ischemia: the elusive search for diagnostic perfection. Ann Intern Med 2003;139:987–95.
Pope JH, Selker HP: Diagnosis of acute cardiac ischemia. Emerg Med Clin North Am 2003;21:27–59.
Turnipseed SD, Trythall WS, Diercks DB, et al. Frequency of acute coronary syndrome in patients with normal electrocardiogram performed during presence or absence of chest pain. Acad Emerg Med 2009;16:495-9.
Sharkey S, Berger C, Brunette D, Henry T. Impact of the electrocardiogram on the delivery of thrombolytic therapy for acute myocardial infarction. Am J Cardiol 1994;73:550–3.
Wagner G. Marriott’s Practical Electrocardiography. 11th edn. Wilkins LW, editor. Philadelphia: 2008, p. 145–62.
Zhou S: An automated algorithm to improve ECG detection of posterior STEMI associated with left circumflex coronary artery occlusion. Comput Cardiol 2006;33:33–6.
Sørensen JT, Terkelsen CJ, Steengaard C, et al. Prehospital troponin T testing in the diagnosis and triage of patients with suspected acute myocardial infarction. Am J Cardiol 2011;107:1436–40. http://doi.org/10.1016/j.amjcard.2011.01.014
Six AJ, Backus BE, Kelder JC. Chest pain in the emergency room: value of the HEART score. Neth Heart 2008;16:191–6. http://doi.org/10.1007/BF03086144
Backus BE, Six AJ, Kelder JC, et al. A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol 2013;168:2153–8. http://doi.org/10.1016/j.ijcard.2013.01.255
Ali D, Fokkert MJ, Slingerland R, et al. Feasibility of pre-hospital chest pain triage at home or in the ambulance by paramedics using the HEART score based upon a single high-sensitive troponin T analysis. Eur Heart J Published online 1 August 2013.
Curtis K, Ramsden C. Emergency and Trauma Care for Nurses and Paramedics. 2015. 2nd edn. Elsevier; Australia.
Sanders M, McKenna KD, Lewis LM, Quick G. Mosby’s Paramedic Textbook, 2012. 4th edn. Elsevier; Australia.