Performance of risk scores for coronary artery disease in patients with chest pain in urgent primary care
| Autor: | A Manten, M Kleton, I H Smits, R P Rietveld, W A M Lucassen, R E Harskamp |
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| Rok vydání: | 2021 |
| Předmět: | |
| Zdroj: | European Heart Journal. 42 |
| ISSN: | 1522-9645 0195-668X |
| Popis: | Background and introduction Chest pain is a common symptom for contacting out-of-hours primary care. One of the critical tasks of general practitioners (GPs) is to swiftly rule out possible life-threatening conditions. Easy-to-use clinical risk scores may help in adequate risk stratification. Purpose To evaluate the diagnostic performance of the Marburg Heart Score (MHS) [1], INTERCHEST [2], Gencer rule [3], and Bruins-Slot rule [4] and compare these scores with unaided clinical judgement among patients with chest pain who are evaluated in urgent primary care. Methods A retrospective, cohort study of patients aged ≥18 years who were evaluated for chest pain at a regional primary care facility in Alkmaar, the Netherlands. The reference standard for the diagnostic performance of risk scores and unaided GP assessment involved a composite endpoint of the occurrence of death from any cause, acute coronary syndrome or coronary revascularization (=major adverse cardiac events; MACE) up to six weeks after initial contact. Diagnostic test properties were evaluated using C-statistics, sensitivity, specificity, positive and negative predictive values (PPV/NPV) and referral rates. Results Out study population involved 664 consecutive patients, of whom 4.8% (n=32) had a MACE event. C-statistics were 0.85 [95%-confidence interval (CI): 0.78–0.92], 0.77 [95%-CI: 0.69–0.84], 0.72 [95%-CI: 0.63–0.81], and 0.72 [95%-CI: 0.63–0.81] for MHS, INTERCHEST, Gencer and Bruins-Slot respectively. Optimal diagnostic accuracy was found for MHS ≥2 (sensitivity=81.3%, specificity=67.1%, PPV=11.1%, NPV=98.6%), INTERCHEST ≥2 (sensitivity=87.5%, specificity=78.8%, PPV=17.3%, NPV=99.1%), Gencer ≥2 (sensitivity 84.4%, specificity=37.8%, PPV 6.4%, NPV=98.0%), and Bruins-Slot ≥2 (sensitivity=90.6%, specificity=40.8%, PPV=7.2%, NPV 98.9%). Physicians referred 157 patients (23.6%) and missed 6 out of 32 MACEs (sensitivity=81.3%, specificity=79.3%, PPV 16.6%, NPV 98.8%). Using INTERCHEST with a referral threshold of ≥2 points, 4 MACEs would have been missed and 162 patients (24.4%) referred. The other risk scores resulted in far higher referral rates. Conclusion The currently available clinical risk scores are safe for use in a low-risk population of patients with chest pain, but do not outperform unaided clinical judgement. Only the INTERCHEST score appears to somewhat improve risk stratification. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): ZonMW-HGOG Components clinical decision rulesPerformance risk scores regarding MACE |
| Databáze: | OpenAIRE |
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