No single component of the history, physical examination, or initial diagnostic testing can reliably exclude ACS, but various clinical risk scores incorporate this information to identify patients at low risk for ACS or serious short-term outcome.
A focused history should be obtained from all stable patients. Historical features of a patient’s chest pain cannot reliably rule in or rule out ACS, but may be associated with a higher or lower likelihood of ACS. A 2015 review that included 58 studies found that pain radiating to both arms, pain similar to prior ischemia, and a change in the pattern of pain over the past 24 hours were the most helpful historical features in predicting ACS. These features had a positive likelihood ratio (LR) ≥ 2.0 and a confidence interval (CI) excluding 1.0.22
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