Appendix 6

Pooled sensitivity, specificity, positive and negative likelihood ratios, odds ratios of signs and symptoms for acute coronary syndrome in patients groups.

		Acute coronary syndrome Non-selected patients			Acute coronary syndrome Selected patients

Symptom			95% CI	I²^a (%)		95%CI	I²^a (%)
Pain in left arm and/or shoulder
Not selected38^,45^,46	Sensitivity	38	18.6 to 59.5	95
Selected (n/a)	Specificity	71	56.9 to 82.6	97
	LR+	1.30	1.13 to 1.47	0
	LR−	0.88	0.78 to 1.00	58
	OR	1.50	1.19 to 1.90	0

Pain in right arm and/or shoulder
Not selected45	Sensitivity	18	9.6 to 26.2	–	23	10.6 to 35.9	–
Selected43	Specificity	95	93.8 to 96.1	–	94	87.2 to 100	–
	LR+	3.78	2.17 to 6.60	–	3.80	1.12 to 12.91	–
	LR−	0.86	0.77 to 0.96	–	0.82	0.98 to 0.98	–
	OR	4.40	2.29 to 8.48	–	46.5	1.19 to 18.20	–

Pain in neck
Not selected46	Sensitivity	35	27.9 to 42.4	–
Selected (n/a)	Specificity	76	72.2 to 79.1	–
	LR+	1.44	1.12 to 1.86	–
	LR−	0.86	0.76 to 0.97	–
	OR	1.69	1.16 to 2.44	–

Pain in back
Not selected38^,45	Sensitivity	13	2.8 to 34.3	86	29	15.3 to 43.2	–
Selected43	Specificity	76	26.7 to 98.6	98	49	35.0 to 63.0	–
ACS38^,43^,45	LR+	1.49	0.62 to 3.56	80	0.57	0.33 to 0.99	–
	LR−	0.93	0.77 to 1.13	87	1.44	1.02 to 2.04	–
	OR	1.59	0.58 to 4.37	80	0.40	0.17 to 0.90	–

Epigastric pain
Not selected23^,36^,39^,45	Sensitivity	12	5.4 to 20.8	97
Selected (n/a)	Specificity	89	82.9 to 94.1	98
	LR+	1.05	0.35 to 3.20	97
	LR−	0.98	0.88 to 1.08	97
	OR	1.08	0.31 to 3.74	97

Oppressive pain56
Not selected23	Sensitivity	56	49.7 to 62.1	–	79	66.9 to 91.2	–
Selected43	Specificity	67	61.8 to 71.7	–	39	25.1 to 52.4	–
	LR+	1.68	1.40 to 2.02	–	1.29	0.99 to 1.69	–
	LR−	0.66	0.56 to 0.77	–	0.54	0.27 to 1.06	–
	OR	2.54	1.82 to 3.56	–	2.39	0.94 to 6.08	–

Vomiting and/or nausea
Not selected25^,36^,38^,39^,44^,45	Sensitivity	26	20.7 to 32.2	91
Selected (n/a)	Specificity	82	74.1 to 88.4	98
	LR+	1.32	1.09 to 1.65	68
	LR−	0.93	0.89 to 0.96	35
	OR	1.43	1.14 to 1.81	63

Sweating
Not selected32^,38^,39^,44	Sensitivity	43	32.2 to 64.9	98
Selected (n/a)	Specificity	68	44.0 to 86.5	99
	LR+	1.34	1.09 to 1.65	76
	LR−	0.85	0.79 to 0.92	40
	OR	1.65	1.39 to 1.95	0

Absence of chest-wall tenderness
Not selected23^,24	Sensitivity	94	91.4 to 96.1	0
Selected (n/a)	Specificity	33	19.7 to 47.9	96
	LR+	1.41	1.12 to 1.78	94
	LR−	0.17	0.11 to 0.26	0
	OR	0.12	7.0 to 21.0	34

Note: Pain in both arms — not applicable.
↵a I²=100% × (Q−df)/Q, where Q is Cochran's heterogeneity statistic and df the degrees of freedom. ACS = acute coronary syndrome. LR+ = positive likelihood ratio. LR− = negative likelihood ratio. OR = odds ratio.