Figure 1
Clinical workflow of patients. ED, Emergency department; ECG, Electrocardiography; CVCU, Cardiovascular care unit.
Figure 2
Recruitment of study participants. ED, Emergency department; ACS, Acute coronary syndrome; STEMI, ST elevation myocardial infarction; NSTEMI, non-ST elevation myocardial infarction.
Table 1
Baseline characteristics.
| DIAGNOSIS | P-VALUE | |||
|---|---|---|---|---|
| ACS (N = 82) | NON-ACS (N = 82) | |||
| Sex | ||||
| Male | 63 (76.8%) | 49 (59.8%) | 0.019 | |
| Female | 19 (23.2%) | 33 (40.2%) | ||
| Age (years) | ||||
| Male <55 | 16 (19.5%) | 22 (26.8%) | ≤0.005 | |
| Male ≥55 | 47 (57.3%) | 28 (34.1%) | ||
| Female <60 | 9 (11%) | 24 (29.3%) | ||
| Female ≥60 | 10 (12.2%) | 8 (9.8%) | ||
| Occupation | ||||
| Public servant | 8 (9.8%) | 10 (12.2%) | 0.092 | |
| Private servant | 48 (58.5%) | 58 (70.7%) | ||
| Unemployed | 26 (31.7%) | 14 (17.1%) | ||
| Education | ||||
| Not completed elementary school | 2 (2.4%) | 0 (0.0%) | 0.061 | |
| Elementary school | 20 (24.4%) | 17 (20.7%) | ||
| Junior high School | 21 (25.6%) | 34 (41.5%) | ||
| Senior high school | 31 (37.8%) | 19 (23.2%) | ||
| Bachelor’s degree | 8 (9.8%) | 12 (14.6%) | ||
| Risk Factors | ||||
| Diabetes mellitus | ||||
| Yes | 35 (42.7%) | 9 (11.0%) | ≤0.000 | |
| No | 47 (57.3%) | 73 (89.0%) | ||
| Smoking | ||||
| Yes | 52 (63.4%) | 42 (51.2%) | 0.114 | |
| No | 30 (36.6%) | 40 (48.8%) | ||
| Hypertension | ||||
| Yes | 52 (63.4%) | 24 (29.3%) | ≤0.000 | |
| No | 30 (36.6%) | 58 (70.7%) | ||
| Dyslipidaemia | ||||
| Yes | 12 (14.6%) | 4 (4.9%) | 0.035 | |
| No | 70 (85.4%) | 78 (95.1%) | ||
| Family history of cardiovascular event | ||||
| Yes | 8 (9.8%) | 0 (0.0%) | ≤0.004 | |
| No | 74 (90.2%) | 82 (100.0%) | ||
| History of a heart attack | ||||
| Yes | 20 (24.4%) | 2 (2.4%) | ≤0.01 | |
| No | 62 (75.6%) | 80 (97.6%) | ||
[i] ACS, acute coronary syndrome.
Table 2
Odds ratio for each question in the chest pain assessment.
| QUESTIONS | DIAGNOSIS | P-VALUE | OR (95% CI) | ||
|---|---|---|---|---|---|
| ACS (N = 82) | NON-ACS (N = 82) | ||||
| Was the chest pain located at the left/middle chest? | |||||
| Yes | 72 (87.8%) | 58 (70.7%) | 0.012 | 2.979 (1.31–6.72) | |
| No | 10 (12.2%) | 24 (29.3%) | |||
| Did the chest pain radiate to the neck? | |||||
| Yes | 9 (11.0%) | 7 (8.5%) | 0.792 | 1.321 (0.46–3.73) | |
| No | 73 (89.0%) | 75 (91.5%) | |||
| Did the chest pain radiate to the back? | |||||
| Yes | 47 (57.3%) | 14 (17.1%) | 0.000 | 6.522 (3.16–13.43) | |
| No | 35 (42.7%) | 68 (82.9%) | |||
| Did the chest pain radiate to the jaw? | |||||
| Yes | 3 (3.7%) | 3 (3.7%) | 1.000 | 1.000 (0.19–5.10) | |
| No | 79 (96.3%) | 79 (96.3%) | |||
| Did the chest pain radiate to the left arm? | |||||
| Yes | 10 (12.2%) | 7 (8.5%) | 0.608 | 1.488 (0.53–4.12) | |
| No | 72 (87.8%) | 75 (91.5%) | |||
| Did the chest pain radiate to the epigastric? | |||||
| Yes | 15 (18.3%) | 13 (15.9%) | 0.836 | 1.188 (0.52–2.68) | |
| No | 67 (81.7%) | 69 (84.1%) | |||
| Was this the first chest pain experience? | |||||
| Yes | 62 (75.6%) | 80 (97.6%) | 0.000 | 0.078 (0.01–0.34) | |
| No | 20 (24.4%) | 2 (2.4%) | |||
| Was the chest pain provoked by activity and relieved by rest? | |||||
| Yes | 13 (15.9%) | 71 (86.6%) | 0.000 | 34.25 (14.37–81.66) | |
| No | 69 (84.1%) | 11 (13.4%) | |||
| Did the chest pain appear during mild activity? | |||||
| Yes | 15 (18.3%) | 11 (13.4%) | 0.521 | 1.445 (0.62–3.36) | |
| No | 67 (81.7%) | 71 (86.6%) | |||
| Did the chest pain appear at rest? | |||||
| Yes | 32 (39.0%) | 0 (0.0%) | 0.000 | N/A | |
| No | 50 (61.0%) | 82 (100%) | |||
| Did you have any previous episode of chest pain? | |||||
| Yes | 20 (24.4%) | 7 (8.5%) | 0.006 | 3.456 (1.37–8.70) | |
| No | 62 (75.6%) | 75 (91.5%) | |||
| Compared to the previous chest pain episode, was this episode provoked by any activities that were less intense than in the previous episode? (n = 27) | |||||
| Yes | 11 (55%) | 0 (0.0%) | 0.036 | N/A | |
| No | 9 (45%) | 7 (100.0%) | |||
| Was the duration of chest pain more than 20 minutes? | |||||
| Yes | 82 (100.0%) | 19 (23.2%) | 0.000 | N/A | |
| No | 0 (0.0%) | 63 (76.8%) | |||
| Did the chest pain result in a pressured/crushing sensation? | |||||
| Yes | 36 (43.9%) | 30 (36.6%) | 0.426 | 1.357 (0.72–2.57) | |
| No | 46 (56.1%) | 52 (63.4%) | |||
| Was the chest pain burning or stabbing? | |||||
| Yes | 41 (50.0%) | 59 (72.0%) | 0.007 | 2.565 (1.34–4.90) | |
| No | 41 (50.0%) | 23 (28.0%) | |||
| Was the chest pain provoked by food ingestion or positional changes or breathing? | |||||
| Yes | 5 (6.1%) | 29 (35.4%) | 0.000 | 8.426 (3.06–23.17) | |
| No | 77 (93.9%) | 53 (64.6%) | |||
[i] ACS, acute coronary syndrome; OR, odds ratio; CI, confidence interval.
Table 3
Multivariate analysis of chest pain assessment.
| VARIABLES | P-VALUE | EXP (β) | 95% CI | |
|---|---|---|---|---|
| LOWER | UPPER | |||
| Step 1 | ||||
| Was the chest pain located at the left/middle chest? (yes) | 0.015 | 5.265 | 1.380 | 20.081 |
| Did the chest pain radiate to the back? (yes) | 0.000 | 9.108 | 2.828 | 29.336 |
| Was this the first chest pain experience? (yes) | 0.032 | 26.300 | 1.322 | 523.039 |
| Was the chest pain provoked by activity and relieved by rest? (no) | 0.000 | 24.599 | 8.625 | 70.163 |
| Did you have any previous chest pain? (yes) | 0.121 | 0.143 | 0.012 | 1.677 |
| Was the chest pain burning or stabbing? (yes) | 0.871 | 0.913 | 0.306 | 2.728 |
| Was the chest pain provoked by food ingestion, positional changes, or breathing? (no) | 0.035 | 5.524 | 1.126 | 27.106 |
| Step 2 | ||||
| Was the chest pain located at the left/middle chest? (yes) | 0.015 | 5.184 | 1.380 | 19.473 |
| Did the chest pain radiate to the back? (yes) | 0.000 | 9.020 | 2.822 | 28.834 |
| Was this the first chest pain experience? (yes) | 0.032 | 25.402 | 1.319 | 489.306 |
| Was the chest pain provoked by activity and relieved by rest? (no) | 0.000 | 24.452 | 8.605 | 69.481 |
| Did you have any previous chest pain? (yes) | 0.124 | 0.144 | 0.012 | 1.697 |
| Was the chest pain provoked by food ingestion, positional changes, or breathing? (no) | 0.029 | 5.284 | 1.185 | 23.572 |
| Step 3 | ||||
| Was the chest pain located at the left/middle chest? (yes) | 0.020 | 4.639 | 1.267 | 16.982 |
| Did the chest pain radiate to the back? (yes) | 0.000 | 8.737 | 2.824 | 27.026 |
| Was this the first chest pain experience? (yes) | 0.114 | 4.209 | 0.709 | 24.965 |
| Was the chest pain provoked by activity and relieved by rest? (no) | 0.000 | 23.604 | 8.485 | 65.663 |
| Was the chest pain provoked by food ingestion or positional changes or breathing? (no) | 0.041 | 4.711 | 1.063 | 20.876 |
| Step 4 | ||||
| Was the chest pain located at the left/middle chest? (yes) | 0.021 | 4.461 | 1.257 | 15.828 |
| Did the chest pain radiate to the back? (yes) | 0.000 | 10.012 | 3.254 | 30.810 |
| Was the chest pain provoked by activity and relieved by rest? (no) | 0.000 | 27.546 | 10.029 | 75.658 |
| Was the chest pain provoked by food ingestion, positional changes, or breathing? (no) | 0.031 | 4.788 | 1.152 | 19.908 |
[i] CI, confidence interval.
Table 4
Multivariate analysis of chest pain assessment adjusted for gender and type 2 diabetes mellitus risk factor.
| VARIABLES | P VALUE | EXP (β) | 95% CI | |
|---|---|---|---|---|
| LOWER | UPPER | |||
| Gender (Male) | 0.061 | 2.986 | 0.952 | 9.369 |
| Diabetes Mellitus (yes) | 0.005 | 6.393 | 1.777 | 23.004 |
| Was the chest pain located at the left/middle chest? (yes) | 0.000 | 4.381 | 1.047 | 18.333 |
| Did the chest pain radiate to the back? (yes) | 0.052 | 12.384 | 3.378 | 45.405 |
| Was the chest pain provoked by activity and relieved by rest? (no) | 0.000 | 34.543 | 10.761 | 110.853 |
| Was the chest pain provoked by food ingestion, positional changes, or breathing? (no) | 0.043 | 4.679 | 0.988 | 22.158 |
[i] CI, confidence interval.
Table 5
Subgroup Analysis Chest Pain Characteristic Difference between Men and Women.
| QUESTIONS | MEN (N = 112) | WOMEN (N = 52) | P-VALUE INTERACTION | ||||||
|---|---|---|---|---|---|---|---|---|---|
| ACS (N = 63) | NON-ACS (N = 49) | P VALUE | OR | ACS (N = 19) | NON-ACS (N = 33) | P VALUE | OR | ||
| Was the chest pain located at the left/middle chest? | |||||||||
| yes | 55 (87.3) | 36 (73.5) | 0.063 | 2.483 (0.936–6.587) | 17 (89.5) | 22 (66.7) | 0.135 | 4.250 (0.829–21.782) | 0.360 |
| no | 8 (12.7) | 13 (26.5) | 2 (10.5) | 11 (33.3) | |||||
| Did the chest pain radiate to the neck? | |||||||||
| yes | 5 (7.9) | 4 (8.2) | 1.000 | 0.970 (0.246–3.821) | 4 (21.1) | 3 (9.1) | 0.400 | 2.667 (0.528–13.477) | 0.277 |
| no | 58 (92.1) | 45 (91.8) | 15 (78.9) | 30 (90.9) | |||||
| Did the chest pain radiate to the back? | |||||||||
| yes | 35 (55.6) | 10 (20.4) | 0.000 | 4.875 (2.075–11.453) | 12 (63.2) | 4 (12.1) | 0.000 | 12.429 (3.063–50.431) | 0.247 |
| no | 28 (44.4) | 39 (79.6) | 7 (36.8) | 29 (87.9) | |||||
| Did the chest pain radiate to the jaw? | |||||||||
| yes | 2 (3.2) | 0 (0) | 0.503 | N/A | 1 (5.3) | 3 (9.1) | 1.000 | 0.556 (0.054–5.752) | 0.062 |
| no | 61 (96.8) | 49 (100) | 18 (94.7) | 30 (90.9) | |||||
| Did the chest pain radiate to the left arm? | |||||||||
| yes | 9 (14.3) | 3 (6.1) | 0.224 | 2.556 (0.653–10.002) | 1 (5.3) | 4 (12.1) | 0.641 | 0.403 (0.042–3.894) | 0.830 |
| no | 54 (85.7) | 46 (93.9) | 18 (94.7) | 29 (87.9) | |||||
| Did the chest pain radiate to the epigastric? | |||||||||
| yes | 11 (17.5) | 7 (14.3) | 0.650 | 2.556 (0.653–10.002) | 4 (21.1) | 6 (18.2) | 1.000 | 1.200 (0.292–4.934) | 0.618 |
| no | 52 (82.5) | 42 (85.7) | 15 (78.9) | 27 (81.8) | |||||
| Was this the first chest pain experience? | |||||||||
| yes | 16 (25.4) | 2 (4.1) | 0.003 | 1.269 (0.453–3.559) | 15 (78.9) | 0 (0) | 0.014 | N/A | 0.144 |
| no | 47 (74.6) | 42 (95.9) | 4 (21.1) | 33 (100) | |||||
| Did the chest pain appear during mild activity? | |||||||||
| yes | 11 (17.5) | 5 (10.2) | 0.276 | 1.862 (0.601–5.767) | 4 (21.1) | 6 (18.2) | 1.000 | N/A | 0.421 |
| no | 52 (82.5) | 44 (89.8) | 15 (78.9) | 27 (81.8) | |||||
| Did the chest pain provoked by activity and relieved by rest? | |||||||||
| yes | 11 (17.5) | 44 (89.8) | 0.000 | 41.600 (13.428–128.882) | 2 (10.5) | 27 (81.8) | 0.000 | 38.250 (6.908–211.799) | 0.428 |
| no | 52 (82.5) | 5 (10.2) | 17 (89.5) | 6 (18.2) | |||||
| Did the chest pain appear at rest? | |||||||||
| yes | 23 (36.5) | 0 (0) | 0.106 | N/A | 9 (47.4) | 0 (0) | 0.000 | N/A | 0.628 |
| no | 40 (63.5) | 49 (100) | 10 (52.6) | 33 (100) | |||||
| Did you have any previous episode of chest pain? | |||||||||
| yes | 15 (23.8) | 5 (10.2) | 0.062 | 2.750 (0.923–8.193) | 5 (26.3) | 2 (6.1) | 0.085 | 5.536 (0.955–32.082) | 0.481 |
| no | 48 (76.2) | 44 (89.8) | 14 (73.7) | 31 (93.9) | |||||
| Compared to the previous chest pain episode, was this episode provoked by any activities that were less intense than in the previous episode? (n = 20) | |||||||||
| yes | 7 (46.7) | 0 (0) | 0.114 | N/A | 4 (80) | 0 (0) | 0.143 | N/A | 0.314 |
| no | 8 (53.3) | 5 (100) | 1 (20) | 2 (100) | |||||
| Was this chest pain episode provoked by daily activities as in the case of previous chest pain? (n = 20) | |||||||||
| yes | 8 (53.3) | 5 (100) | 0.114 | N/A | 1 (20) | 2 (100) | 0.143 | N/A | 0.314 |
| no | 7 (46.7) | 0 (0) | 4 (80) | 0 (0) | |||||
| Was the duration of chest pain more than 20 minutes? | |||||||||
| yes | 63 (100) | 13 (26.5) | 0.000 | N/A | 19 (100) | 6 (18.2) | 0.000 | N/A | 0.016 |
| no | 0 (0) | 36 (73.5) | 0 (0) | 27 (81.8) | |||||
| Did the chest pain result in a pressured/crushing sensation? | |||||||||
| yes | 27 (42.9) | 15 (30.6) | 0.258 | 1.700 (0.774–3.731) | 9 (47.4) | 15 (45.5) | 0.894 | 1.080 (0.348–3.349) | 0.294 |
| no | 36 (57.1) | 34 (69.4) | 10 (52.6) | 18 (54.5) | |||||
| Was the chest pain burning or stabbing? | |||||||||
| yes | 35 (55.6) | 16 (32.7) | 0.026 | 2.578 (1.186–5.606) | 6 (31.6) | 7 (21.2) | 0.406 | 1.714 (0.478–6.151) | 0.012 |
| no | 28 (44.4) | 33 (67.3) | 13 (68.6) | 26 (78.8) | |||||
| Was the chest pain provoked by food ingestion or positional changes or breathing? | |||||||||
| yes | 1 (1.6) | 18 (36.7) | 0.000 | 36.000 (4.592–282.260) | 4 (21.1) | 11 (33.3) | 0.526 | 1.875 (0.501–7.013) | 0.082 |
| no | 63 (98.4) | 31 (63.3) | 15 (78.9) | 22 (66.7) | |||||
[i] ACS, Acute Coronary Syndrome.
Figure 3
Receiver operating characteristic curve for chest pain assessment. With a sensitivity of 92.1% and 1-specificity of 84.1%, a cut-off point of 0.37 was obtained. ROC, receiver operating characteristic; AUC, area under the curve.
Figure 4
DETAK C mobile application user interface. DETAK C mobile application collecting chest pain characteristics information from the patient, analysing the data, and guiding the patient to the appropriate hospital.