Diagnosing acute coronary syndrome in primary care: comparison of the physicians' risk estimation and a clinical decision rule

Slot, M.H.E. Bruins; Rutten, Frans H.; Heijden, Geert J. M. G. van der; Geersing, Geert Jan; Glatz, Jan F. C.; Hoes, Arno W.

doi:10.1093/fampra/cmq116

Cited by 28 publications

(33 citation statements)

References 19 publications

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“…Various studies have shown that tools to enable such individual risk prediction may enable a more cost-effective use of healthcare resources, a better classification of patients in risk groups than physicians' judgement only, and minimizes patient burden [4]–[10]. Not surprisingly, prediction research has been a topic of increasing interest over the last few decades in the medical literature [11], [12], [13].…”

Section: Introductionmentioning

confidence: 99%

Search Filters for Finding Prognostic and Diagnostic Prediction Studies in Medline to Enhance Systematic Reviews

et al. 2012

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BackgroundThe interest in prognostic reviews is increasing, but to properly review existing evidence an accurate search filer for finding prediction research is needed. The aim of this paper was to validate and update two previously introduced search filters for finding prediction research in Medline: the Ingui filter and the Haynes Broad filter.Methodology/Principal FindingsBased on a hand search of 6 general journals in 2008 we constructed two sets of papers. Set 1 consisted of prediction research papers (n = 71), and set 2 consisted of the remaining papers (n = 1133). Both search filters were validated in two ways, using diagnostic accuracy measures as performance measures. First, we compared studies in set 1 (reference) with studies retrieved by the search strategies as applied in Medline. Second, we compared studies from 4 published systematic reviews (reference) with studies retrieved by the search filter as applied in Medline. Next – using word frequency methods – we constructed an additional search string for finding prediction research. Both search filters were good in identifying clinical prediction models: sensitivity ranged from 0.94 to 1.0 using our hand search as reference, and 0.78 to 0.89 using the systematic reviews as reference. This latter performance measure even increased to around 0.95 (range 0.90 to 0.97) when either search filter was combined with the additional string that we developed. Retrieval rate of explorative prediction research was poor, both using our hand search or our systematic review as reference, and even combined with our additional search string: sensitivity ranged from 0.44 to 0.85.Conclusions/SignificanceExplorative prediction research is difficult to find in Medline, using any of the currently available search filters. Yet, application of either the Ingui filter or the Haynes broad filter results in a very low number missed clinical prediction model studies.

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Section: Introductionmentioning

confidence: 99%

Search Filters for Finding Prognostic and Diagnostic Prediction Studies in Medline to Enhance Systematic Reviews

et al. 2012

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“…Within this population, benign conditions such as thoracic wall complaints, gastric disease or psychiatric and somatoform disease, largely outnumber cases of ACS [ 3 - 5 ]. In specialised care facilities such as coronary care units, 50% of patients presenting with chest pain are diagnosed with ACS, whereas in primary care, ACS is diagnosed in no more than 1.5-22% of cases [ 6 - 8 ]. Referring every patient with chest complaints would overwhelm secondary care facilities, however the GP is faced with serious diagnostic dilemmas since milder diseases with beneficial outcome can mimic ACS and vice versa [ 9 ].…”

Section: Introductionmentioning

confidence: 99%

“…With regard to chest pain, only few signs and symptoms, for example, the absence of pain on chest palpation or presence of pain on exertion, generate discriminative strength in diagnostic studies, although to a limited extent [ 9 , 13 , 14 ]. Altogether, clinical signs and symptoms are inappropriate for ruling out ACS or lack additive value above the clinical judgment by the GP, which on itself is correct in a majority of cases [ 6 ]. Weighing more abstract factors (e.g.…”

Section: Introductionmentioning

confidence: 99%

“…A low threshold for referring patients with chest complaints to secondary care is an effective strategy for the GP to avert missed cases of ACS [ 19 ]. In the Netherlands, this strategy results in 78% of referred patients that are ACS negative in the emergency room (positive predictive value (PPV) is 22%), whereas ACS is present in 5% of patients that are not referred (negative predictive value (NPV) is 95%) and the outcome is probably not severely affected by initially not referring (specificity and sensitivity of clinical assessment by GP: 55%, resp 81%) [ 6 , 20 ]. To enhance triage by a GP and reduce patient burden in secondary care, new diagnostic tools should become available [ 21 ].…”

Section: Introductionmentioning

confidence: 99%

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The value of signs, symptoms and plasma heart-type fatty acid-binding protein (H-FABP) in evaluating patients presenting with symptoms possibly matching acute coronary syndrome: background and methods of a diagnostic study in primary care

Willemsen¹,

Buntinx

Winkens³

et al. 2014

BMC Fam Pract

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BackgroundChest complaints presented to a general practitioner (GP) are frequently caused by diseases which have advantageous outcomes. However, in some cases, acute coronary syndrome (ACS) is present (1.5-22% of cases). The patient’s signs, symptoms and electrocardiography results are insufficient diagnostic tools to distinguish mild disease from ACS. Therefore, most patients presenting chest complaints are referred to secondary care facilities where ACS is then ruled out in a majority of patients (78%). Recently, a point of care test for heart-type fatty acid-binding protein (H-FABP) using a low cut-off value between positive and negative of 4 ng/ml has become available. We aim to study the role of this point of care device in triage of patients presenting chest complaints possibly due to ACS, in primary care. Our research protocol is presented in this article. Results are expected in 2015.Methods/DesignParticipating GPs will register signs and symptoms in all patients presenting chest complaints possibly due to ACS. Point of care H-FABP testing will also be performed. Our study will be a derivation study to identify signs and symptoms that, combined with point of care H-FABP testing, can be part of an algorithm to either confirm or rule out ACS. The diagnostic value for ACS of this algorithm in general practice will be determined.DiscussionA safe diagnostic elimination of ACS by application of the algorithm can be of significant clinical relevance. Improved triage and thus reduction of the number of patients with chest complaints without underlying ACS, that are referred to secondary care facilities, could lead to a substantial cost reduction.Trial registrationClinicalTrials.gov, NCT01826994, accepted April 8th 2013.

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“…The outcome of GPs' diagnostic capability has been investigated and clinical decision rules have been suggested based on history, symptoms, signs, and electrocardiogram findings [1–5]. Elevation of cardiac-specific troponins, for example, Troponin T, is one of the cornerstones in diagnosing acute myocardial infarction (AMI) in hospital care [6].…”

Section: Introductionmentioning

confidence: 99%

Point-of-Care Troponin T Testing in the Management of Patients with Chest Pain in the Swedish Primary Care

Nilsson

Andersson²,

Borgqúist

et al. 2013

International Journal of Family Medicine

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Objective. To investigate the diagnostic accuracy and clinical benefit of point-of-care Troponin T testing (POCT-TnT) in the management of patients with chest pain. Design. Observational, prospective, cross-sectional study with followup. Setting. Three primary health care (PHC) centres using POCT-TnT and four PHC centres not using POCT-TnT in the southeast of Sweden. Patients. All patients ≥35 years old, contacting one of the primary health care centres for chest pain, dyspnoea on exertion, unexplained weakness, and/or fatigue with no other probable cause than cardiac, were included. Symptoms should have commenced or worsened during the last seven days. Main Outcome Measures. Emergency referrals, patients with acute myocardial infarctions (AMI), or unstable angina (UA) within 30 days of study enrolment. Results. 25% of the patients from PHC centres with POCT-TnT and 43% from PHC centres without POCT-TnT were emergently referred by the GP (P = 0.011 ). Seven patients (5.5%) from PHC centres with POCT-TnT and six (8.8%) from PHC centres without POCT-TnT were diagnosed as AMI or UA (P = 0.369). Two patients with AMI or UA from PHC centres with POCT-TnT were judged as missed cases in primary health care. Conclusion. The use of POCT-TnT may reduce emergency referrals but probably at the cost of an increased risk to miss patients with AMI or UA.

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Diagnosing acute coronary syndrome in primary care: comparison of the physicians' risk estimation and a clinical decision rule

Abstract: The GP classified patients as ACS or no ACS more adequately than the CDR, judged by the AUC. However, the use of a CDR in patients that are considered at low risk for ACS by the GP could reduce the amount of missed myocardial infarctions.

Cited by 28 publications

References 19 publications

Search Filters for Finding Prognostic and Diagnostic Prediction Studies in Medline to Enhance Systematic Reviews

Search Filters for Finding Prognostic and Diagnostic Prediction Studies in Medline to Enhance Systematic Reviews

The value of signs, symptoms and plasma heart-type fatty acid-binding protein (H-FABP) in evaluating patients presenting with symptoms possibly matching acute coronary syndrome: background and methods of a diagnostic study in primary care

Point-of-Care Troponin T Testing in the Management of Patients with Chest Pain in the Swedish Primary Care

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