Appendix 5

Pooled sensitivity, specificity, positive and negative likelihood ratios, odds ratios of signs and symptoms for acute myocardial infarction in patient groups.

		Acute myocardial infarction Non-selected patients			Acute myocardial infarction Selected patients

Symptom			95% CI	I²^a (%)		95% CI	I²^a (%)
Pain in left arm and/or shoulder
Not selected41	Sensitivity	33	25.4 to 41.8	–	54	50.2 to 56.9	0
Selected19^,28^,30^,33^,42	Specificity	76.3	74.5 to 78.2	–	65	56.4 to 72.8	87
	LR+	1.42	1.10 to 1.83	–	1.49	1.20 to 1.85	71
	LR−	0.87	0.77 to 0.99	–	0.76	0.66 to 0.88	57
	OR	1.631	12 to 2.39	–	2.00	1.39 to 2.88	65

Pain in right arm and/or shoulder
Not selected24	Sensitivity	15	5.9 to 23.7	–	32	25.1 to 40.8	77
Selected19^,28^,30^,33^,42	Specificity	95	92.8 to 97.0	–	86	78.4 to 91.2	85
	LR+	2.89	1.40 to 5.98	–	2.35	1.44 to 3.84	80
	LR−	0.90	0.81 to 1.00	–	0.81	0.66 to 1.00	96
	OR	3.22	1.41 to 7.36	–	3.09	1.63 to 5.85	80

Pain in both arms
Not selected (n/a)	Sensitivity				32	25.1 to 40.8	77
Selected19	Specificity				86	78.4 to 91.2	85
	LR+				2.35	1.44 to 3.84	80
	LR−				0.81	0.66 to 1.00	96
	OR				3.09	1.63 to 5.85	80

Pain in neck
Not selected41	Sensitivity	14	8.2 to 20.4	–	24	18.3 to 30.2	65
Selected30^,33^,42	Specificity	90	89.0 to 91.6	–	75	71.6 to 77.7	0
	LR+	1.48	0.94 to 2.31	–	0.99	0.83 to 1.17	0
	LR−	0.95	0.88 to 1.02	–	1.00	0.95 to 1.07	0
	OR	1.55	0.92 to 2.61	–	0.98	0.78 to 1.23	0

Pain in back
Not selected (n/a)	Sensitivity				25	22.0 to 28.2	0
Selected30^,33^,42	Specificity				71	66.4 to 75.6	45
	LR+				0.84	0.62 to 1.14	59
	LR−				1.07	0.96 to 1.19	60
	OR	0.78				0.52 to 1.19	59

Epigastric pain
Not selected23	Sensitivity	10	3.9 to 15.3	–	5	2.1 to 10.8	89
Selected34^,36^,37^,39	Specificity	93	91.1 to 95.2	–	91	85.0 to 95.4	99
	LR+	1.44	0.73 to 2.83	–	0.73	0.61 to 0.87	0
	LR−	0.97	0.91 to 1.04	–	1.04	1.02 to 1.05	0
	OR	1.49	0.71 to 3.12	–	0.69	0.57 to 0.85	0

Oppressive pain
Not selected23^,24^,27^,35^,41	Sensitivity	60	53.7 to 66.0	77	77	71.3 to 81.2	0
Selected28^,29^,31	Specificity	58	55.0 to 60.2	87	35	28.7 to 41.3	48
	LR+	1.42	1.32 to 1.53	36	1.79	1.07 to 1.30	0
	LR−	0.69	0.61 to 0.80	64	0.70	0.52 to 0.86	0
	OR	2.06	1.60 to 2.53	51	1.77	1.25 to 2.51	0

Vomiting and/or nausea
Not selected24^,36^,39^,41	Sensitivity	34	25.3 to 44.1	84	29	12.5 to 51.5	97
Selected20^,22^,26^,28^,29	Specificity	77	71.1 to 81.3	97	81	76.6 to 85.1	73
	LR+	1.41	1.17 to 1.72	64	1.42	0.76 to 2.64	92
	LR−	0.83	0.83 to 0.96	52	0.82	0.66 to 1.03	94
	OR	1.62	1.22 ro 2.14	59	1.73	0.71 to 4.12	93

Sweating
Not selected21^,24^,27^,39^,41^,44	Sensitivity	45	36.0 to 54.0	91	41	22.9 to 60.5	95
Selected20^,22^,29^,31	Specificity	84	78.6 to 88.0	97	85	69.2 to 94.7	98
	LR+	2.92	1.97 to 4.32	95	2.44	1.42 to 4.20	81
	LR−	0.69	0.60 to 0.78	81	0.72	0.56 to 0.91	90
	OR	4.54	2.47 to 8.36	94	3.81	1.88 to 7.70	83

Absence of chest wall tenderness
Not selected23^,24^,27^,35	Sensitivity	92	85.5 to 96.4	89
Selected (n/a)	Specificity	36	20.5 to 51.8	99
	LR+	1.47	1.23 to 1.75	97
	LR−	0.23	0.18 to 0.29	0
	OR	0.17	0.12 to 0.23	26

↵a I² = 100% × (Q−df)/Q, where Q is Cochran's heterogeneity statistic and df the degrees of freedom. LR+ = positive likelihood ratio. LR− = negative likelihood ratio. OR = odds ratio.