Article

Diagnostic accuracy of clinical prediction rules to exclude acute coronary syndrome in the emergency department setting: A systematic review

Department of Emergency Medicine, University of Ottawa, Ottawa, Ontario.
Canadian Journal of Emergency Medicine (Impact Factor: 0.66). 07/2008; 10(4):373-82.
Source: PubMed

ABSTRACT We sought to determine the diagnostic accuracy of clinical prediction rules to exclude acute coronary syndrome (ACS) in the emergency department (ED) setting.
We searched MEDLINE, EMBASE, Web of Science and the Cochrane Database of Systematic Reviews. We contacted content experts to identify additional articles for review. Reference lists of included studies were hand searched. We selected articles for review based on the following criteria: 1) enrolled consecutive ED patients; 2) incorporated variables from the history or physical examination, electrocardiogram and cardiac biomarkers; 3) did not incorporate cardiac stress testing or coronary angiography into prediction rule; 4) based on original research; 5) prospectively derived or validated; 6) did not require use of a computer; and 7) reported sufficient data to construct a 2 x 2 contingency table. We assessed study quality and extracted data independently and in duplicate using a standardized data extraction form.
Eight studies met inclusion criteria, encompassing 7937 patients. None of the studies verified the prediction rule with a reference standard on all or a random sample of patients. Six studies did not report blinding prediction rule assessors to reference standard results, and vice versa. Three prediction rules were prospectively validated. Sensitivities and specificities ranged from 94% to 100% and 13% to 57%, and positive and negative likelihood ratios from 1.1 to 2.2 and 0.01 to 0.17, respectively.
Current prediction rules for ACS have substantial methodological limitations and have not been successfully implemented in the clinical setting. Future methodologically sound studies are needed to guide clinical practice.

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    • "However, experts agree that it is very difficult to get the risk of missed ACS below 1%, and, pending malpractice reform, most emergency physicians in the United States are unwilling to accept even a 1% miss rate [24]. Despite showing a correlation with the risk of ACS and adverse outcome, none of these risk stratification systems have gained widespread acceptance in clinical practice [25]. Preliminary results of a prospective validation of the HEART score were reported at the 2010 Congress of the European Society of Cardiology [26]. "
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    ABSTRACT: BACKGROUND:: Studies have individually reported the relationship of age, cardiac risk factors, and history of preexisting coronary artery disease (CAD) for predicting acute coronary syndromes in chest pain patients undergoing cardiac stress testing. In this study, we investigate the interplay of all these factors on the incidence of acute coronary syndromes to develop a tool that may assist physicians in the selection of appropriate chest pain patients for stress testing. METHODS:: Retrospective analysis of a prospectively acquired database of consecutive chest pain patients undergoing nuclear stress testing. Backward stepwise logistic regression was used to develop a model for predicting risk of 30-day acute coronary events (ACE) using information obtained from age, sex, cardiac risk factors, and history of preexisting CAD. RESULTS:: A total of 800 chest pain patients underwent nuclear stress testing. ACE occurred in 74 patients (9.3%). Logistic regression analysis found only 6 factors predictive of ACE: age, male sex, preexisting CAD, diabetes, and hyperlipidemia. Area under the receiver operator characteristic curve of this model for predicting ACE was 0.767 (95% confidence interval, 0.719-0.815). There were no cases of ACE in the 173 patients with predicted probability estimates ≤2.5% (95% confidence interval, 0%-2.1%). CONCLUSIONS:: A regression model using age, sex, preexisting CAD, diabetes, and hyperlipidemia is predictive of 30-day ACE in chest pain patients undergoing nuclear stress testing. Prospective studies need to be performed to determine whether this model can assist physicians in the selection of appropriate low-to-intermediate risk chest pain patients for nuclear stress testing.
    Critical pathways in cardiology 12/2012; 11(4):171-176. DOI:10.1097/HPC.0b013e31826f367f
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    • "However, experts agree that it is very difficult to get the risk of missed ACS below 1%, and, pending malpractice reform, most emergency physicians in the United States are unwilling to accept even a 1% miss rate [24]. Despite showing a correlation with the risk of ACS and adverse outcome, none of these risk stratification systems have gained widespread acceptance in clinical practice [25]. Preliminary results of a prospective validation of the HEART score were reported at the 2010 Congress of the European Society of Cardiology [26]. "
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    ABSTRACT: BACKGROUND: The HEART score uses elements from patient History, Electrocardiogram, Age, Risk Factors, and Troponin to obtain a risk score on a 0- to 10-point scale for predicting acute coronary syndromes (ACS). This investigation seeks to improve on the HEART score by proposing the HEARTS(3) score, which uses likelihood ratio analysis to give appropriate weight to the individual elements of the HEART score as well as incorporating 3 additional "S" variables: Sex, Serial 2-hour electrocardiogram, and Serial 2-hour delta troponin during the initial emergency department valuation. METHODS: This is a retrospective analysis of a prospectively acquired database consisting of 2148 consecutive patients with non-ST-segment elevation chest pain. Interval analysis of likelihood ratios was performed to determine appropriate weighting of the individual elements of the HEART(3) score. Primary outcomes were 30-day ACS and myocardial infarction. RESULTS: There were 315 patients with 30-day ACS and 1833 patients without ACS. Likelihood ratio analysis revealed significant discrepancies in weight of the 5 individual elements shared by the HEART and HEARTS(3) score. The HEARTS(3) score outperformed the HEART score as determined by comparison of areas under the receiver operating characteristic curve for myocardial infarction (0.958 vs 0.825; 95% confidence interval difference in areas, 0.105-0.161) and for 30-day ACS (0.901 vs 0.813; 95% confidence interval difference in areas, 0.064-0.110). CONCLUSION: The HEARTS(3) score reliably risk stratifies patients with chest pain for 30-day ACS. Prospective studies need to be performed to determine if implementation of this score as a decision support tool can guide treatment and disposition decisions in the management of patients with chest pain.
    The American journal of emergency medicine 05/2012; 30(9). DOI:10.1016/j.ajem.2012.03.017 · 1.15 Impact Factor
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    • "c o m / m a t h As no universally-accepted standardised tool currently exists for the methodological appraisal of studies of CPRs (Fritz, 2009), previous systematic reviews have used a variety of means to evaluate the quality of included studies. Some reviews have utilised standardised tools that were developed to appraise prognostic (Beneciuk et al., 2009) and diagnostic studies (Bachmann et al., 2004; Hess et al., 2008). Criticism in this approach has focused upon recognising that methodological standards for the development of CPRs differ to that of other types of studies (Stanton et al., 2009). "
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    ABSTRACT: To identify, appraise and determine the clinical readiness of diagnostic, prescriptive and prognostic Clinical Prediction Rules (CPRs) in the physiotherapy management of Low Back Pain (LBP). MEDLINE, EMBASE, CINAHL, AMED and the Cochrane Database of Systematic Reviews were searched from 1990 to January 2010 using sensitive search strategies for identifying CPR and LBP studies. Citation tracking and hand-searching of relevant journals were used as supplemental strategies. Two independent reviewers used a two-phase selection procedure to identify studies that explicitly aimed to develop one or more CPRs involving the physiotherapy management of LBP. Diagnostic, prescriptive and prognostic studies investigating CPRs at any stage of their development, derivation, validation, or impact-analysis, were considered for inclusion using a priori criteria. 7453 unique records were screened with 23 studies composing the final included sample. Two reviewers independently extracted relevant data into evidence tables using a standardised instrument. Identified studies were qualitatively synthesized. No attempt was made to statistically pool the results of individual studies. The 23 scientifically admissible studies described the development of 25 unique CPRs, including 15 diagnostic, 7 prescriptive and 3 prognostic rules. The majority (65%) of studies described the initial derivation of one or more CPRs. No studies investigating the impact phase of rule development were identified. The current body of evidence does not enable confident direct clinical application of any of the identified CPRs. Further validation studies utilizing appropriate research designs and rigorous methodology are required to determine the performance and generalizability of the derived CPRs to other patient populations, clinicians and clinical settings.
    Manual therapy 06/2011; 17(1):9-21. DOI:10.1016/j.math.2011.05.001 · 1.76 Impact Factor
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