'Chest Pain Typicality' in Suspected Acute Coronary Syndromes and the Impact of Clinical Experience
'Chest Pain Typicality' in Suspected Acute Coronary Syndromes and the Impact of Clinical Experience
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DOI：
10.1016/j.amjmed.2015.04.012
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发表时间：
2015-10-01
影响因子：
5.9
通讯作者：
Greaves, Kim
中科院分区：
文献类型：
--
作者：
Carlton, Edward W.;Than, Martin;Greaves, Kim
背景：对于疑似急性冠状动脉综合征的患者，医生依靠胸痛病史来做出治疗决策，特别是在通过心电图和肌钙蛋白检测不能立即诊断的情况下。本研究的目的是建立“胸痛典型性”的鉴别价值和临床医生经验对预测急性心肌梗死和存在显著冠状动脉疾病的影响。方法：这项前瞻性单中心观察性研究在英国一家综合医院急诊科进行。我们招募了连续的胸痛和非诊断性心电图的成年人，治疗医生确定延迟肌钙蛋白检测是必要的。医生根据自己的临床判断，记录胸痛是典型的还是非典型的急性冠状动脉综合征。根据研究生经历，医生被定义为“有经验”或“新手”。急性心肌梗死的诊断采用高灵敏度肌钙蛋白（hs-cTn）测定，冠状动脉疾病的诊断采用血管造影。结果：总体而言，912例患者有胸痛的典型评估，其中114/912（12.5%）有急性心肌梗死，157/912（17.2%）进行了血管造影。在接受血管造影的患者中，90/157（57.3%）有hs-cTn升高，其中60（66.7%）有明显的冠状动脉疾病。157例患者中67例（42.7%）血管造影未见hs-cTn升高；其中31例（46.2%）有明显的冠状动脉疾病。对于急性心肌梗死的诊断，胸痛典型性的曲线下面积（AUC）为0.54（95%可信区间[CI]， 0.49-0.60）。预测显著冠状动脉疾病时，hs-cTn升高的AUC为0.54 (95% CI, 0.40-0.67)，无hs-cTn升高的AUC为0.45 （95% CI, 0.31-0.59）。当由经验丰富的医生评估时，急性心肌梗死诊断的特异性更高，为65.8% (95% CI, 63.1%-68.7%)，而新手为55.4% （95% CI, 53.9%-56.8%）。结论：在非诊断性心电图的情况下，主观解释“胸痛典典性”在评估疑似急性冠状动脉综合征时具有有限的歧视性价值。更多的临床经验提高了作为常规工具的准确性，但没有提高整体的区分能力。(C) 2015年作者。Elsevier Inc.出版。
BACKGROUND: Physicians rely upon chest pain history to make management decisions in patients with suspected acute coronary syndromes, particularly where the diagnosis is not immediately apparent through electrocardiography and troponin testing. The objective of this study was to establish the discriminatory value of "typicality of chest pain" and the effect of clinician experience, for the prediction of acute myocardial infarction and presence of significant coronary artery disease.METHODS: This prospective single-center observational study was undertaken in a UK General Hospital emergency department. We recruited consecutive adults with chest pain and a nondiagnostic electrocardiogram, for whom the treating physician determined that delayed troponin testing was necessary. Using their own clinical judgment, physicians recorded whether the chest pain described was typical or atypical for acute coronary syndrome. Physicians were defined as "experienced" or "novice" according to postgraduate experience. Acute myocardial infarction was adjudicated using a high-sensitivity troponin (hs-cTn) assay, whereas coronary artery disease was adjudicated angiographically.RESULTS: Overall, 912 patients had typicality of chest pain assessed, of whom 114/912 (12.5%) had an acute myocardial infarction and 157/912 (17.2%) underwent angiography. In patients undergoing angiography, 90/157 (57.3%) had hs-cTn elevation, of whom 60 (66.7%) had significant coronary artery disease. Sixty-seven of 157 (42.7%) patients had angiography without hs-cTn elevation; of these, 31 (46.2%) had significant coronary artery disease. For the diagnosis of acute myocardial infarction, chest pain typicality had an area under the curve (AUC) of 0.54 (95% confidence interval [ CI], 0.49-0.60). For the prediction of significant coronary artery disease with hs-cTn elevation AUC: 0.54 (95% CI, 0.40-0.67), and without hs-cTn elevation AUC: 0.45 (95% CI, 0.31-0.59). When assessed by experienced physicians, specificity for the diagnosis of acute myocardial infarction was higher at 65.8% (95% CI, 63.1%-68.7%) vs 55.4% (95% CI, 53.9%-56.8%) for novices.CONCLUSIONS: Subjective interpretation of "typicality of chest pain" is of limited discriminatory value in the assessment of suspected acute coronary syndromes, in the context of a nondiagnostic electrocardiogram. Greater clinical experience improves accuracy as a rule-in tool but does not improve overall discriminatory ability. (C) 2015 The Authors. Published by Elsevier Inc.