Can emergency physicians 'rule in' and 'rule out' acute myocardial infarction with clinical judgement?
Can emergency physicians 'rule in' and 'rule out' acute myocardial infarction with clinical judgement?
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DOI：
10.1136/emermed-2014-203832
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发表时间：
2014-11-01
影响因子：
3.1
通讯作者：
Lewis, Philip S.
中科院分区：
文献类型：
--
作者：
Body, Richard;Cook, Gary;Lewis, Philip S.
目的探讨急诊医生格式塔在诊断疑似心源性胸痛患者中的准确性，无论是单独诊断，还是结合初始肌钙蛋白水平和心电图结果进行诊断。临床医生使用Likert五点量表记录他们在陈述时的‘格式塔’，对结果视而不见。入院血样中检测肌钙蛋白T和高敏肌钙蛋白T(hs-cTnT；均为罗氏诊断电泳仪)水平。所有患者在症状高峰后至少12小时进行肌钙蛋白检测。结果本研究共纳入458例患者，其中81例(17.7%)为急性心肌梗死。对于急性心肌梗死，仅临床医生格式塔的受试者工作特征曲线下面积为0.76(95%可信区间0.70~0.82)。对于初始肌钙蛋白和心电图正常的患者，如果临床医生认为诊断为“可能不是”或“肯定不是”，则23.1%(95%可信区间19%至28%)敏感性为100%(95%可信区间95.6%至100%)的患者可避免入院。使用hs-cTnT，即使只对“可能”或“确定”的ACS患者进行进一步调查，也可以达到100%的敏感性，这将使41.7%的患者立即出院。结论仅用格式塔不能单独用于排除或排除ACS。通过结合临床医生格式塔和入院时的心电图和肌钙蛋白水平，我们发现100%的敏感性，而不需要连续的肌钙蛋白检测。这些发现有可能减少疑似急性冠脉综合征患者不必要的住院人数，但在考虑临床实施之前必须进行前瞻性验证。
Objective To determine the diagnostic accuracy of emergency physician gestalt in emergency department (ED) patients with suspected cardiac chest pain, both alone and in combination with initial troponin level and ECG findings.Methods We prospectively included patients presenting to the ED with suspected cardiac chest pain. Clinicians recorded their 'gestalt' at the time of presentation using a five-point Likert scale, blinded to outcome. Troponin T and high-sensitivity troponin T (hs-cTnT; both Roche Diagnostics Elecsys) levels were measured in admission blood samples. All patients underwent troponin testing at least 12 h after peak symptoms. The primary outcome was acute myocardial infarction (AMI).Results 458 patients were included in this study, 81 (17.7%) of whom had AMI. Clinician gestalt alone had an area under the receiver operating characteristic curve of 0.76 (95% CI 0.70 to 0.82) for AMI. Immediately discharging patients with normal initial troponin and ECG in whom the clinician felt the diagnosis was 'probably not' or 'definitely not' acute coronary syndrome (ACS) would have avoided admission for 23.1% (95% CI 19% to 28%) patients with 100% sensitivity (95% CI 95.6% to 100%). With hs-cTnT, 100% sensitivity could have been achieved even if only patients with 'probable' or 'definite' ACS were investigated further, which would have allowed 41.7% patients to be discharged immediately.Conclusions Gestalt alone cannot be used to 'rule in' or 'rule out' ACS. By combining clinician gestalt with the admission ECG and troponin level, we found 100% sensitivity without the need for serial troponin testing. These findings have the potential to reduce unnecessary hospital admissions for suspected ACS but must be prospectively validated before considering clinical implementation.