Streamlining Differential Diagnosis of Coronary Heart Disease in a Pri- mary Care Clinic: Atypical and Typical Symptoms and Their Combina- tions

Background: We sought to identify the most predictive symptoms of coronary heart disease (CHD) in the setting of a very busy community primary care clinic. By examining the variability, distribution and frequency of symptoms singly and in combination we hoped to streamline the process of correctly identifying a patient presenting with CHD. Methods: All 449 patients suspected of having CHD by one primary physician (1995-2004) were evaluated by thallium scan, treadmill ergometry, and/or coronary angiography, as well as ECG and creatine phosphokinase /troponin levels. Group 1 included 216 subjects (117 males, 98 females, mean age 69.7±11.2 years) diagnosed as having acute coronary syndrome, stable angina pectoris or acute myocardial infarction. Group 2 included 233 (126 males, 108 females, mean age 65.2±12.1 years) subjects whose comprehensive evaluations ruled out CHD. Results: The leading symptom in Groups 1 and 2 was chest pain [80%] vs [80.3%] (NS). Dyspnea was present in 10% and 5%; (p<0.037) patients, and jaw pain in 11% and 1% (p<0.0001) patients. The symptom combinations found more frequently in Group 1 were chest pain+jaw pain (7% vs 1. 04%; p<0.0001) and dyspnea+sweating (2.8% vs 0%, p<0.01). Conclusion: Isolated symptoms (jaw pain, dyspnea) and combined symptoms (chest pain+jaw pain, dyspnea+sweating) were more specific for CHD than classical chest pain.