A Clinical Decision Rule to Identify Emergency Department Patients at Low Risk for Acute Coronary Syndrome Who Do Not Need Objective Coronary Artery Disease Testing: The No Objective Testing Rule

被引:34
作者
Greenslade, Jaimi H. [1 ,2 ,3 ]
Parsonage, William [1 ,2 ,3 ]
Than, Martin [4 ,5 ]
Scott, Adam [1 ,3 ]
Aldous, Sally [5 ]
Pickering, John W. [5 ]
Hammett, Christopher J. [1 ,2 ]
Cullen, Louise [1 ,2 ,3 ]
机构
[1] Royal Brisbane & Womens Hosp, Brisbane, Qld, Australia
[2] Univ Queensland, Sch Med, Brisbane, Qld, Australia
[3] Queensland Univ Technol, Sch Publ Hlth, Brisbane, Qld 4001, Australia
[4] Univ Otago, Sch Med, Christchurch, New Zealand
[5] Christchurch Hosp, Christchurch, New Zealand
关键词
ACUTE MYOCARDIAL-INFARCTION; ACUTE CARDIAC ISCHEMIA; CHEST-PAIN; DIAGNOSTIC PROTOCOL; MISSED DIAGNOSIS; EUROPEAN-SOCIETY; HEART-DISEASE; VALIDATION; TROPONIN; OUTCOMES;
D O I
10.1016/j.annemergmed.2015.08.006
中图分类号
R4 [临床医学];
学科分类号
1002 ; 100602 ;
摘要
Study objective: We derive a clinical decision rule for ongoing investigation of patients who present to the emergency department (ED) with chest pain. The rule identifies patients who are at low risk of acute coronary syndrome and could be discharged without further cardiac testing. Methods: This was a prospective observational study of 2,396 patients who presented to 2 EDs with chest pain suggestive of acute coronary syndrome and had normal troponin and ECG results 2 hours after presentation. Research nurses collected clinical data on presentation, and the primary endpoint was diagnosis of acute coronary syndrome within 30 days of presentation to the ED. Logistic regression analyses were conducted on 50 bootstrapped samples to identify predictors of acute coronary syndrome. A rule was derived and diagnostic accuracy statistics were computed. Results: Acute coronary syndrome was diagnosed in 126 (5.3%) patients. Regression analyses identified the following predictors of acute coronary syndrome: cardiac risk factors, age, sex, previous myocardial infarction, or coronary artery disease and nitrate use. A rule was derived that identified 753 low-risk patients (31.4%), with sensitivity 97.6% (95% confidence interval [CI] 93.2% to 99.5%), negative predictive value 99.6% (95% CI 98.8% to 99.9%), specificity 33.0% (95% CI 31.1% to 35.0%), and positive predictive value 7.5% (95% CI 6.3% to 8.9%) for acute coronary syndrome. This was referred to as the no objective testing rule. Conclusion: We have derived a clinical decision rule for chest pain patients with negative early cardiac biomarker and ECG testing results that identifies 31% at low risk and who may not require objective testing for coronary artery disease. A prospective trial is required to confirm these findings.
引用
收藏
页码:478 / 489
页数:12
相关论文
共 48 条
[1]   Exercise testing in chest pain units: Rationale, implementation, and results [J].
Amsterdam, EA ;
Kirk, JD ;
Diercks, DB ;
Lewis, WR ;
Turnipseed, SD .
CARDIOLOGY CLINICS, 2005, 23 (04) :503-+
[2]   Immediate exercise testing to evaluate low-risk patients presenting to the emergency department with chest pain [J].
Amsterdam, EA ;
Kirk, JD ;
Diercks, DB ;
Lewis, WR ;
Turnipseed, SD .
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, 2002, 40 (02) :251-256
[3]   Testing of Low-Risk Patients Presenting to the Emergency Department With Chest Pain A Scientific Statement From the American Heart Association [J].
Amsterdam, Ezra A. ;
Kirk, J. Douglas ;
Bluemke, David A. ;
Diercks, Deborah ;
Farkouh, Michael E. ;
Garvey, J. Lee ;
Kontos, Michael C. ;
McCord, James ;
Miller, Todd D. ;
Morise, Anthony ;
Newby, L. Kristin ;
Ruberg, Frederick L. ;
Scordo, Kristine Anne ;
Thompson, Paul D. .
CIRCULATION, 2010, 122 (17) :1756-1776
[4]   ACC/AHA 2007 guide lines for the management of patients with unstable Angina/Non-ST-Elevation myocardial infraction - Executive summary [J].
Anderson, Jeffrey L. ;
Adams, Cynthia D. ;
Antman, Elliott M. ;
Bridges, Charles R. ;
Califf, Robert M. ;
Casey, Donald E., Jr. ;
Chavey, William E., II ;
Fesmire, Francis M. ;
Hochman, Judith S. ;
Levin, Thomas N. ;
Lincoff, A. Michael ;
Peterson, Eric D. ;
Theroux, Pierre ;
Wenger, Nanette Kass ;
Wright, R. Scott ;
Smith, Sidney C., Jr. ;
Jacobs, Alice K. ;
Adams, Cynthia D. ;
Riegel, Barbara .
JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY, 2007, 50 (07) :652-726
[5]   The TIMI risk score for unstable angina/non-ST elevation MI - A method for prognostication and therapeutic decision making [J].
Antman, EM ;
Cohen, M ;
Bernink, PJLM ;
McCabe, CH ;
Horacek, T ;
Papuchis, G ;
Mautner, B ;
Corbalan, R ;
Radley, D ;
Braunwald, E .
JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, 2000, 284 (07) :835-842
[6]  
Aroney CN, 2006, MED J AUSTRALIA, V184, pS1
[7]   Bootstrap methods for developing predictive models [J].
Austin, PC ;
Tu, JV .
AMERICAN STATISTICIAN, 2004, 58 (02) :131-137
[8]  
Bhuiya Farida A, 2010, NCHS Data Brief, P1
[9]   The Manchester Acute Coronary Syndromes (MACS) decision rule for suspected cardiac chest pain: derivation and external validation [J].
Body, Richard ;
Carley, Simon ;
McDowell, Garry ;
Pemberton, Philip ;
Burrows, Gillian ;
Cook, Gary ;
Lewis, Philip S. ;
Smith, Alexander ;
Mackway-Jones, Kevin .
HEART, 2014, 100 (18) :1462-1468
[10]   Population Trends of Recurrent Coronary Heart Disease Event Rates Remain High [J].
Briffa, Tom G. ;
Hobbs, Michael S. ;
Tonkin, Andrew ;
Sanfilippo, Frank M. ;
Hickling, Siobhan ;
Ridout, Stephen C. ;
Knuiman, Matthew .
CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES, 2011, 4 (01) :107-113