Can emergency physicians ‘rule in’ and ‘rule out’ acute myocardial infarction with clinical judgement?

Abstract

ObjectiveTo 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.MethodsWe 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).Results458 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.ConclusionsGestalt 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.

Identifying Patients Suitable for Discharge After a Single-Presentation High-Sensitivity Troponin Result: A Comparison of Five Established Risk Scores and Two High-Sensitivity Assays

“…This may be an explanation for the superior diagnostic performance of the m-Goldman score. The approach of deriving risk scores from large prospective datasets is commonplace in the literature (8,16,17,18 (23). Accepting that subjective interpretation may be important in risk-stratifying patients with chest pain (23,24), we acknowledge that the performance of each pathway may be enhanced by taking into account clinician gestalt.…”

‘Chest Pain Typicality’ in Suspected Acute Coronary Syndromes and the Impact of Clinical Experience

“…We therefore suggest that there should be a focus on the clinical application of accelerated diagnostic protocols, which combine risk scores with high-sensitivity troponin testing (21,(31)(32)(33)(34), rather than unstructured subjective clinical assessment or gestalt (20).…”

“…However, these studies have tended to either include patients with diagnostic ECG changes , focus on specific chest pain characteristics rather than overall typicality, or use M A N U S C R I P T A C C E P T E D ACCEPTED MANUSCRIPT 5 research nurses to extract this information. Although it is evident that unstructured clinical judgment or gestalt has an important role to play in the overall risk assessment of acute chest pain patients (20), the subjective interpretation of typicality of chest pain and the impact that clinical experience may have upon its diagnostic accuracy remain poorly understood.…”

Exploring the Potential of Predictive Analytics and Big Data in Emergency Care

“…57 Clinicians have cited performance reproducibility, cumbersome implementation, and exclusion of and inferiority to clinician gestalt as reasons for this. [80][81][82] Some barriers may be more easily addressed with new-wave predictive tools. Automated message alerts within electronic medical records and data feedback about diagnostic and prognostic information, when carefully used, have the potential to enhance implementation and uptake.…”