International Journal of Cardiology 102 (2005) 87 – 93

www.elsevier.com/locate/ijcard

How well can signs and symptoms predict AMI

in the Malaysian population?
A.M. Bulgibaa,*, M. Razazb
a
Department of Social and Preventive Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
b
School of Computing Sciences, University of East Anglia, Norwich NR4 7TJ, United Kingdom

Received 21 October 2003; received in revised form 12 March 2004; accepted 25 April 2004
Available online 1 August 2004

Abstract

The aim of the study was to use data from an electronic medical record system (EMR) to look for factors that would help us diagnose
acute myocardial infarction (AMI) with the ultimate aim of using these factors in a decision support system for chest pain. We extracted 887
records from the electronic medical record system (EMR) in Selayang Hospital, Malaysia. We cleaned the data, extracted 69 possible
variables and performed univariate and multivariate analysis. From the univariate analysis we find that 22 variables are significantly
associated with a diagnosis of AMI. However, multiple logistic regression reveals that only 9 of these 22 variables are significantly related to
a diagnosis of AMI. Race (Indian), male sex, sudden onset of persistent crushing pain, associated sweating and a history of diabetes mellitus
are significant predictors of AMI. Pain that is relieved by other means and history of heart disease on treatment are important predictors of a
diagnosis other than AMI. The degree of accuracy is high at 80.5%. There are 13 factors that are significant in the univariate analysis but are
not among the nine significant factors in the multivariate analysis. These are location of pain, associated palpitations, nausea and vomiting;
pain relieved by rest, pain aggravated by posture, cough, inspiration and exertion; age more than 40, being a smoker and abnormal chest wall
and face examination. We believe that these findings can have important applications in the design of an intelligent decision support system
for use in medical care as the predictive capability can be further refined with the use of intelligent computational techniques.
D 2004 Elsevier Ireland Ltd. All rights reserved.

Keywords: Acute myocardial infarction; Diagnosis; Prediction; Multiple logistic regression

1. Introduction deaths in England, it was found that for cases involving

Acute chest pain in adults is a frequently encountered
symptom in all healthcare settings [1]. It warrants immediate
attention and assessment because of the high rates of
morbidity and mortality associated with the pathology. It is a
symptom that can be quite perplexing for the doctor because
of the wide range of differential diagnoses possible for the
patient. Differential diagnoses can range from the most life
threatening of illnesses to simple problems that can be
treated in the outpatient clinic. It is vital for the emergency
physician not to miss a diagnosis of AMI as ischaemic heart
disease is one of the leading causes of morbidity and
mortality in the western world [2]. In a review of sudden
* Corresponding author.
E-mail address: awang@um.edu.my (A.M. Bulgiba).
myocardial tissue, death was ascribed to ischaemic heart
disease in 82.4% of cases [3]. In the elderly, hypertension
and ischaemic heart disease have been found to be
significant predictors of emergency room admissions [4].
There are many risk factors for AMI. In the elderly, for
example it has been shown that hyperlipidaemia, smoking,
hypertension, diabetes and a family history of heart disease
are independently and strongly related to the risk of AMI
[5]. In addition to these, males are often at substantially
higher risk than females and renal impairment does appear
to influence mortality for AMI [6]. Hypertension treatment
has been shown to be of benefit in hypertensives with
diabetes, ischaemic heart disease and high global cardio-
vascular risk although in smokers, these should be
accompanied by efforts to induce smoking cessation [7].
Blood pressure was at least as strongly associated with

0167-5273/$ - see front matter D 2004 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ijcard.2004.04.002
88 A.M. Bulgiba, M. Razaz / International Journal of Cardiology 102 (2005) 87–93
cardiovascular events in Asian populations compared to
Australasian populations [8]. Throughout middle and old
age, blood pressure is strongly and directly related to
vascular (and overall) mortality, without any evidence of a
threshold down to at least 115/75 mm Hg [9].
The importance of diabetes mellitus in the aetiology of
AMI cannot be over-emphasised although the incidence
varies between ethnic groups. A study of Turkish and
Sirunam–Asian migrants in the Netherlands [10] showed a
high prevalence of ischaemic heart disease in young migrant
Asians with diabetes and in the Slovak Republic, every fifth
diabetic patient has ischaemic heart disease [11].
Chest pain possesses the characteristic of occasionally
being vague but sometimes it is fairly localised and having
distinct characteristics that would immediately alarm an
experienced physician. When this occurs, a confirmatory
investigation such as an electrocardiogram (ECG) and/or
cardiac enzymes is definitely warranted. Localisation of
chest pain may have some limited value (although not that
predictive) in the diagnosis of myocardial infarction [12] but
a focused history and physical examination followed by an
ECG remain the key tools for the diagnosis of myocardial
infarction [13]. In children, the diagnosis of chest pain is less
clear-cut and there are grounds for ordering further inves-
tigations like echocardiograms, ECG and chest X-rays
especially when such children are seen for the first time for
heart murmurs or chest pain. Nonetheless, these investiga-
tions are expensive and should be added only when clinically
warranted by the history and physical examination [14].
The aim of the study was to see how well factors from
history and physical examination predict a diagnosis of
acute myocardial infarction (AMI) in Malaysians with the
further aim of later using these factors in researching a
decision support system for chest pain.
2. Materials and methods
2.1. Source of data
We obtained the dataset from Selayang Hospital, a
tertiary level hospital in Malaysia. This hospital is unique
in that it is the first hospital in Malaysia to use an
electronic medical record (EMR) system and thus is able
to record and store accurate and comprehensive details
about a patient’s illness in an electronic database right
from the point of entry until discharge. The hospital
information system (HIS) has source On-line Transaction
Processing (OLTP) data stored in a large database.
Basically the entire EMR consists of forms created by
hospital staff before the hospital began operations 4 years
ago. There are a number of forms used for this purpose
and depending on the type of illness, there are a number
of fields that are required for the project. All records of
patients seen in the Emergency Department for chest pain
from 20 August 1999 (when the hospital opened) to 9
August 2002 and clerked using the chest pain clerking
form were extracted for this study.
Selayang Hospital has a specific form for patients with
chest pain and the database is a rich source of data on which
many studies can be done. All data from this form was
extracted for records which fitted the criteria above. No
identification data other than the medical record number
(MRN) and financial number were required to identify the
record. This ensured that confidentiality was preserved.
To extract the dataset from the hospital we used a
specialised data-mining tool called Speedminer as the
database was constructed for flexibility rather than for easy
data mining. After processing the information using
Speedminer, we extracted a total of 887 records, which
was exported into an MS Excel spreadsheet and subse-
quently exported to MS Access.
2.2. Data cleaning and pre-processing
Data cleaning and pre-processing was performed before
any analysis was carried out. This involved accuracy
checking, treatment of missing values, recategorisation and
recoding of fields and feature construction. The data was
then analysed using various statistical techniques. A total of
77 variables were analysed with respect to AMI. Frequency
tables and descriptive statistics were run for all the variables
and relevant graphs such as scatter plots and histograms were
used to examine the data distribution and to detect outliers in
the data. Outliers were carefully checked against the original
data and were only corrected where it was felt that they were
clearly errors in entry. We used the diagnosis on discharge as
the definitive diagnosis. This is the diagnosis as confirmed
by specialist physicians after taking into consideration ECG
readings and other laboratory investigations. Physicians who
provided the definitive diagnoses were not necessarily the
same ones who treated the subjects in the Emergency
Department as they came from the Medicine Department
rather than the Emergency Department and all cases of AMI
were treated as inpatients.
2.3. Missing value analysis and treatment
Some data was missing, probably because the attending
doctor did not see any need to fill in such data. The range of
missing data was variable and depended on the variable but
ranged between 0% and 10%. We were able to analyse and
treat for missing values in numeric fields. First the
distributions of the variables were examined to see whether
they deviated from known distributions. To do this, histo-
grams, P–P plots and Q–Q plots of the numeric fields were
created. Histograms can be used for looking at the
distribution is a general way but comparison with any
distribution is less precise. To be more precise, one can use
P–P plots and Q–Q plots where there is a comparison with
the expected values if such a field is normally distributed.
Alternatively, one can use a statistical test like the One-
 A.M. Bulgiba, M. Razaz / International Journal of Cardiology 102 (2005) 87–93 89

sample Kolomogorov–Smirnov test. This test is used to test Table 1

Independent variables selected for the study
the hypothesis that a sample comes from a particular
distribution (Uniform, Normal, or Poisson). The value of Group Fields
the Kolmogorov–Smirnov Z is based on the largest absolute Demographic Age, citizen, race, sex, marital status
difference between the observed and the theoretical cumu- Nature of chest pain Location, onset, pattern, quality
Radiation of pain Jaw, left arm, laterally, neck, locally,
lative distributions. The downside is that deviations from the
other parts
theoretical distribution caused by outliers will be a problem Relieving factors Leaning forward, sitting up, GTN,
so practically speaking, one might like to use a combination rest, other means
of graphs and the Kolomogorov–Smirnov test to determine Aggravating factors Posture, meals, coughing, inspiration,
whether a field approximates some sort of known distribu- exertion
Associated heart/lung symptoms Cough, dyspnoea, oedema,
tion or not. If the data does not deviate too much from a
orthopnoea, palpitations
normal distribution, then the mean will be a good value to Other associated symptoms Collapse, headache, dizziness, fever,
use as a replacement for the missing values. Otherwise, if it numbness, nausea, sweating,
deviates too much from the Normal distribution, then a vomiting, fainting
global constant or the median may be a better value to use to Cardiac risk factors Age N40, diabetes mellitus,
family history, hypertension,
replace the missing values. The distributions appear to be
physical inactivity, obesity,
more or less normal in shape. The values of the constants smoking, known case defaulted
are taken to be the average of the maximum and minimum treatment, known case on treatment,
normal values and as these values are normally distributed high cholesterol levels
in the population, these should be fair values to use. An General examination Pulses, pulse rate, respiratory rate,
systolic BP, diastolic BP
analysis of the means before and after replacement of
Heart/lung examination factors Air entry, breath sounds, chest
missing values see little change in the means, leading to the expansion, chest wall, crepitations,
conclusion that replacing the missing values will have little heart sounds, JVP, percussion, pleural
impact on the overall result. However, for the statistical rub, praecordium, rhonchi
analysis of the data, the actual values are used so as not to Other examination factors Abdomen, central nervous system
(CNS), eye, face,
distort the true picture.

2.4. Analysed variables
Variables selected for analysis were all variables thought
to have any relationship to AMI. Table 1 displays and
groups these variables.
2.5. Statistical tests
The t-test and the Mann–Whitney U-test (where the
variances were not homogenous) were performed to
compare the means of AMI and non-AMI patients for these
variables—age, pulse rate, systolic and diastolic blood
pressure (BP) [15]. Before the t-test was used, normality
assumptions were assessed using the Kolmogorov–Smirnov
test and homogeneity of variances were tested using the
Levene’s test. The v 2 test (with continuity correction for
22 tables) and odds ratios (ORs) were performed to look
for relationships between categorical variables [16]. These
variables are divided into various groups—demographic
factors, nature of chest pain, radiation of chest pain,
relieving factors, associated factors, aggravating factors,
cardiac risk factors and examination factors. Multiple
logistic regression was carried out for all categorical
variables with respect to acute myocardial infarction as the
dependent variable [17]. Three different logistic regression
techniques were used—the enter method, forward likelihood
ratio and backward likelihood ratio. Interaction was care-
fully examined and likely interaction terms were tested
before the final model was produced.
All univariate statistical tests were carried out using a
significance level of 0.05. All multiple logistic regression
models were built using p=0.05 for entry and p=0.10 for
removal.
2.6. Biases and limitations
There are some limitations to our analysis. We are
aware that the data is from a hospital and does not include
those who suffered from and died of AMI outside the
hospital or those who suffered from silent myocardial
infarcts and were not admitted to the hospital. It is,
however, difficult to obtain data from such patients and
there is no way of determining what proportion of patients
has been missed in this way. We are not also able to
provide information about the number of subjects in the
sample who had not been appropriately treated in the
Emergency Department or had been misdiagnosed as such
information was not available.
3. Results
A total of 887 records were analysed. The mean age of
patients was 53.84 years (standard deviation 13.09). There
were 649 males (73.2%) and 238 females (26.8%). Malays
formed the biggest proportion of patients (43.4%), followed
by Chinese (27.1%), Indians (25.7%) and other races
(3.8%). Almost all the patients were Malaysians (98.5%).
90 A.M. Bulgiba, M. Razaz / International Journal of Cardiology 102 (2005) 87–93

3.1. Quantitative variables Table 3

Demographic factors and nature of paina

Table 2 looks at the difference in certain quantitative Variable AMI (%) v 2 p-value Odds ratio (95% CI)
variables between AMI patients and non-AMI patients. The Sex b0.001 2.48 (1.66, 3.71)
t-test was applied for all quantitative variables except where Male 208/649 (32.0)
Female 38/238 (16.0)
assumptions of normality and homogeneity of variance for
Total 246/887
its use could not be met. Where the assumptions were not Location 0.009 1.51 (1.11, 2.05)
met, the Mann–Whitney U-test was used. Four quantitative Retrosternal 117/358 (32.7)
variables were analysed—age, pulse rate, systolic and Other 129/529 (24.4)
diastolic blood pressure (BP). All of them except for Total 246/887
Onset b0.001 3.34 (2.36, 4.74)
diastolic BP are significantly different in both AMI and
Sudden 190/513 (37.0)
non-AMI groups. AMI patients are on average older than Other 56/374 (15.0)
non-AMI patients, have a significantly lower mean pulse Total 242/887
rate and lower mean systolic BP. Pattern b0.001 4.35 (2.99, 6.35)
Persistent 202/531 (38.0)
Other 44/356 (12.4)
3.2. Demographic factors and nature of chest pain
Total 240/887
Quality b0.001 2.96 (2.16, 4.06)
Table 3 looks at demographic factors and nature of chest Crushing 147/361 (40.7)
pain. Four demographic factors were examined (Malaysian Other 99/526 (18.8)
citizenship, marital status, race and sex) and four factors Total 241/887
a
related to the nature of the chest pain were examined here Demographic factors examined—Malaysian citizenship, marital status,
(location, onset, pattern and quality). Of the demographic race and sex. Nature of the chest pain were examined here—location, onset,
pattern and quality.
factors, only sex shows a definite relationship with AMI.
Males are more likely to be diagnosed with acute
myocardial infarction compared to females (OR 2.48, 95% 3.4. Relieving and associated factors
CI 1.66, 3.71).
As far as nature of chest pain is concerned, location of We considered relieving and associated factors for
pain is associated with AMI with those reporting retrosternal AMI. Five ways whereby chest pain could be relieved
pain more likely to have AMI compared to those who were examined (leaning forward, sitting up, glyceryl
complained of any other site (OR 1.51, 95% CI 1.11, 2.05). trinitrate or GTN, rest and other means). The results are
Those with sudden onset pain are also more likely to have shown in Table 4.
AMI compared to other manner of onset (OR 3.34, 95% CI Pain that is relieved by rest is less likely to be diagnosed
2.36, 4.74) and persistent pain is more likely to be as AMI (OR 0.54, 95% CI 0.36, 0.80). However, pain that is
diagnosed as AMI compared to any other pattern (OR relieved by other means is more likely to be diagnosed as
4.35, 95% CI 2.99, 6.35). Patients with crushing pain are
more likely to be diagnosed as AMI compared to other Table 4
quality of pain (OR 2.96, 95% CI 2.16, 4.06). Relieving and associated factors for AMI
Variable AMI (%) v 2 p-value Odds ratio (95% CI)
3.3. Radiation of chest pain Relieved by rest 0.002 0.54 (0.36, 0.80)
Yes 44/230 (19.1)
Six factors related to radiation of chest pain were No 154/505 (30.5)
Total 198/735
examined—radiation to jaw, radiation to left arm, radiation Relieved by b0.001 1.98 (1.40, 2.79)
laterally, radiation to neck, radiation locally and radiation to other means
other parts. None of these factors are significantly associated Yes 116/340 (34.1)
with AMI (not shown in any table). No 82/395 (20.8)
Total 198/735
Nausea 0.001 1.80 (1.26, 2.55)
Yes 109/267 (40.8)
Table 2 No 98/353 (27.8)
T-test for quantitative variables Total 207/620
Sweating b0.001 3.69 (2.46, 5.56)
Quantitative AMI mean Non-AMI Levene’s test p-value Yes 165/378 (43.7)
variable (S.D.) mean (S.D.) p-value No 42/242 (17.4)
Age 55.60 (12.09) 53.17 (13.39) 0.098 0.013 Total 207/620
Pulse rate 82.17 (23.48) 86.07 (21.86) 0.04 0.012a Vomiting b0.001 2.26 (1.46, 3.50)
Systolic BP 133.82 (28.87) 140.66 (27.04) 0.462 0.001 Yes 55/112 (49.1)
Diastolic BP 86.62 (20.54) 86.25 (16.79) 0.001 0.190a No 152/508 (29.9)
a
Denotes Mann–Whitney. Total 207/620
 A.M. Bulgiba, M. Razaz / International Journal of Cardiology 102 (2005) 87–93 91

AMI (OR 1.98, 95% CI 1.40, 2.79). Five cardiac or Table 6

Multiple logistic regression (backward stepwise) of AMI as dependent
respiratory associated symptoms were examined in this
variable
category—cough, dyspnoea, oedema, orthopnoea, and pal-
Independent b (S.E.) p-value Odds ratio
pitations. Of these, only palpitations are significantly
variable (95% CI)
associated with AMI but in an inverse relationship.
Constant 3.653 (0.331) b0.001
Patients with palpitations are less likely to be diagnosed
Race (Indian) 0.508 (0.218) 0.020 0.60 (0.39, 0.92)
with AMI (OR 0.18, 95% CI 0.02, 0.76). Other than Sex (male) 0.665 (0.228) 0.004 1.95 (1.24, 3.04)
cardiac/respiratory factors, nine other associated symptoms Onset (sudden) 0.665 (0.210) 0.002 1.94 (1.29, 2.94)
were examined—collapse, headache, dizziness, fever, Pattern (persistent) 0.969 (0.218) b0.001 2.63 (1.72, 4.04)
nausea, numbness, sweating, vomiting and fainting. Of Quality (crushing) 0.850 (0.193) b0.001 2.34 (1.60, 3.42)
Relieved by 0.673 (0.192) b0.001 1.96 (1.34, 2.86)
these, patients complaining of nausea (OR 1.80, 95% CI
other means
1.26, 2.55), sweating (OR 3.69, 95% CI 2.46, 5.56) and Nausea 0.386 (0.201) 0.055 1.47 (0.99, 2.18)
vomiting (OR 2.26, 95% CI 1.46, 3.50) are more likely to Sweating 0.879 (0.194) b0.001 2.41 (1.65, 3.52)
be diagnosed with AMI. Vomiting 0.459 (0.261) 0.078 1.58 (0.95, 2.64)
Aggravated by 1.303 (0.776) 0.093 0.27 (0.06, 1.24)
posture
3.5. Aggravating factors
Aggravated by 1.236 (0.677) 0.068 0.29 (0.08, 1.10)
inspiration
Five aggravating factors of chest pain were examined— Age N 40 0.359 (0.190) 0.059 1.43 (0.99, 2.08)
posture, meals, cough inspiration and exertion. Patients Diabetes mellitus 0.592 (0.230) 0.010 1.81 (1.15, 2.84)
complaining that their chest pain is aggravated by posture Heart disease 1.027 (0.221) b0.001 0.36 (0.23, 0.55)
on treatment
(OR 0.13, 95% CI 0.01, 0.50) cough (OR 0.11, 95% CI 0,
Abdomen 1.751 (1.087) 0.107 0.17 (0.02, 1.46)
0.70), inspiration (OR 0.20, 95% CI 0.05, 0.57) and Overall percentage
exertion (OR 0.65, 95% CI 0.46, 0.91) are less likely to be correct (Step 48)
diagnosed with AMI. These results are not shown in any 80.5%
table.

3.6. Cardiac risk factors 3.7. Examination factors

Table 5 illustrates results for cardiac risk factors. Ten Fifteen examination factors were examined—abdomen,
cardiac risk factors were examined—age more than 40, air entry, breath sounds, central nervous system (CNS),
diabetes mellitus, family history of heart disease, hyper- chest expansion, chest wall, lung crepitations, eye, face,
tension, physical inactivity, obesity, smoking, known case of heart sounds, jugular venous pressure (JVP), chest percus-
heart disease defaulted treatment, known case of heart sion, presence of pleural rub, appearance of praecordium
disease still on treatment and high cholesterol levels. and presence of rhonchi. Due to the nature of the electronic
Patients over the age of 40 are more likely to be diagnosed medical record, examination of the patient was recorded as
with AMI (OR 1.46, 95% CI 1.05, 2.02). Smokers are also either normal or abnormal or signs were present or absent.
more likely to be diagnosed with AMI (OR 2.11, 95% CI Where findings were abnormal, some comments would be
1.51, 2.94). However, patients who are known heart cases attached to the notes. However, in many cases, we were not
still on treatment are less likely to be diagnosed with AMI able to elicit meaningful comments about the types of
(OR 0.40, 95% CI 0.27, 0.58). abnormalities observed so we are unable to analyse these
properly. Of the heart/lung examination factors, only
examination of the chest wall is significantly related to
diagnosis of AMI. Patients with an abnormal chest wall is
Table 5
Cardiac risk factors and AMI less likely to be diagnosed with AMI (OR 0.13, 95% CI 0,
Variable AMI (%) v 2 p-value Odds ratio (95% CI)
0.79). Other examination findings are not related to
increased or decreased likelihood of being diagnosed with
Age N40 0.025 1.46 (1.05, 2.02)
Yes 129/377 (34.2) AMI. Because little meaningful analysis can be performed
No 94/357 (26.3) here, we have omitted presenting this in a table.
Total 223/734
Smoking b0.001 2.11 (1.51, 2.94) 3.8. Multiple logistic regression
Yes 121/305 (39.7)
No 102/429 (23.8)
Total 223/734
Table 6 shows logistic regression for AMI performed
Still on treatment b0.001 0.40 (0.27, 0.58) using the backward stepwise method. We used three different
Yes 48/257 (18.7) methods (enter, forward stepwise and backward stepwise) to
No 175/477 (36.7) determine which of the three would be the most suitable and
Total 223/734 parsimonious. After evaluation of these three methods, the
92 A.M. Bulgiba, M. Razaz / International Journal of Cardiology 102 (2005) 87–93
best and the most parsimonious model would appear to be
backward stepwise model as this model offers all significant
factors which are common to all three models while retaining
sufficiently high overall percentage which is correct. We
entered 62 variables into the model and evaluated the results.
At each step we specified p=0.05 for entry and p=0.10 for
removal from the model. p-values in the table are final
multivariate p-values, which are obtained after adjustment
for all other variables in the model. All nine common factors,
which are found to be significant in the logistic regression
analysis, are significant in the univariate analysis, indicating
that they are not confounded by other factors. The variables
are race (Indian), sex (male), sudden onset of pain, pattern of
pain (persistent), quality of pain (crushing), pain that is
relieved by other means, associated sweating, history of
diabetes mellitus and history of heart disease on treatment.
The degree of accuracy is quite high at 80.5%. This means
that less than 20% of cases cannot be predicted by these
factors and would require input of other factors.
There are 13 factors which are significant in the
univariate analysis but are not among the nine significant
factors in the multivariate analysis. These are location of
pain, associated palpitations, nausea and vomiting; pain
relieved by rest, pain aggravated by posture, cough,
inspiration and exertion; age more than 40, being a smoker
and abnormal chest wall and face examination.
4. Discussion
There are a few interesting findings in this analysis. Quite
a number of factors investigated here have been well studied
before and it is thus not surprising to find them to be
significant. We would naturally expect to find AMI patients
to be older than non-AMI patients. We would not, however,
expect to find lower pulse rates and lower diastolic blood
pressure in AMI patients unless there has been some
deterioration in cardiac function. However, this is not borne
out in the diagnosis made by the attending physician and
clinically speaking we really should not expect to find these
to be different so perhaps further study needs to be done on
these. We had expected to find sex and ethnicity (Indians) to
be significant factors in Malaysia as literature from other
countries including neighbouring Singapore [18–20] have
reported these to be risk factors for AMI. Sex is definitely
associated with AMI (both univariate and multivariate
analyses confirm this to be true) but univariate analysis fails
to show any relationship between AMI and ethnicity.
However, Indians are shown to have a lower (and not
higher) risk of having AMI in the multivariate analysis. This
is surprising and we cannot offer any explanation for this. We
are not that surprised to find that the location of pain;
although significant in the univariate analysis, is not
significant after adjustment for other effects as this is a
subjective symptom and similar findings elsewhere bears
this out [12]. Having said that, we tend to conclude that
persistent, crushing pain of sudden onset accompanied by
sweating (most likely an autonomic response to pain) remain
strong predictors of AMI and may be more important than
localisation of pain. We are not surprised to find that pain
relieved by rest is not statistically significant after adjustment
for other variables as this is more characteristic of angina
rather than AMI. Aggravation of pain by any means does not
stand up to multivariate analysis and we would tend to
conclude that aggravating factors may not be important as
predictors of AMI. We do find the non-significance of age
N40 and smoking in the multivariate analysis odd as both are
highly significant risk factors in the univariate analysis. This
needs to be looked into carefully in the future. Diabetes, as
expected, remains a very important predictor of AMI [21,22]
and we are not at all surprised by these results. On the other
hand, we failed to find a relationship between AMI and high
cholesterol levels, family history and hypertension despite
studies confirming the existence of these. Whether this is
peculiar to the sample we had or is purely by chance is not
possible to determine at this point.
We found in this sample that having heart disease but still
on treatment made it less likely for a patient to be diagnosed
as a case of AMI. This could be due to some other diagnosis
being made, such as stable or unstable angina and needs to
be looked into carefully. We put this down to the lower
likelihood of getting AMI for heart patients who are on
proper follow-up treatment. We are not surprised to find that
examination factors are less important compared to other
factors in diagnosing AMI as there are few (if any) specific
signs that a patient is suffering from AMI.
The factors studied in this paper confirm the value of a
good history in diagnosing AMI. The importance of this
cannot be over-emphasised as the high predictive value
(80% of diagnoses can be predicted from just these data
alone) based on only a few important points raises the
possibility of AMI diagnosis based on history reinforced by
ECG and cardiac enzyme markers.
We realise that there are some limitations to our analysis.
The possibility of some bias occurring because we have
limited our sample to hospital patients cannot be excluded.
However, our main aim was to obtain some predictive signs
and symptoms to enable us to develop a decision support
system relevant to the Malaysian population so we believe
that this is possibly the best way we can go about
accomplishing this. We also believe that these findings
can have important applications in the design of an
intelligent decision support system for use in medical care
as the predictive capability can be further refined with the
use of intelligent computational techniques.
Acknowledgments
We would like to thank the Ministry of Health, Malaysia
and the Selayang Hospital for permission to extract data
from their database for this project.
 A.M. Bulgiba, M. Razaz / International Journal of Cardiology 102 (2005) 87–93
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