Ruling out coronary artery disease in primary care: development and validation of a simple prediction rule

Abstract

Background: Chest pain can be caused by various conditions, with life-threatening cardiac disease being of greatest concern. Prediction scores to rule out coronary artery disease have been developed for use in emergency settings. We developed and validated a simple prediction rule for use in primary care. Methods:We conducted a cross-sectional diagnostic study in 74 primary care practices in Germany. Primary care physicians recruited all consecutive patients who presented with chest pain (n = 1249) and recorded symptoms and findings for each patient (derivation cohort). An independent expert panel reviewed follow-up data obtained at six weeks and six months on symptoms, investigations, hospital admissions and medications to determine the presence or absence of coronary artery disease. Adjusted odds ratios of relevant variables were used to develop a prediction rule. We calculated measures of diagnostic accuracy for different cut-off values for the prediction scores using data derived from another prospective primary care study (validation cohort). Results:The prediction rule contained five determinants (age/sex, known vascular disease, patient assumes pain is of cardiac origin, pain is worse during exercise, and pain is not reproducible by palpation), with the score ranging from 0 to 5 points. The area under the curve (receiver operating characteristic curve) was 0.87 (95% confidence interval [CI] 0.83-0.91) for the derivation cohort and 0.90 (95% CI 0.87-0.93) for the validation cohort. The best overall discrimination was with a cut-off value of 3 (positive result 3-5 points; negative result ≤ 2 points), which had a sensitivity of 87.1% (95% CI 79.9%-94.2%) and a specificity of 80.8% (77.6%-83.9%). Interpretation:The prediction rule for coronary artery disease in primary care proved to be robust in the validation cohort. It can help to rule out coronary artery disease in patients presenting with chest pain in primary care. AbstractPreviously published at www.cmaj.ca @@

Presentation of Coronary Artery Disease in a Chiropractic Clinic: A Report of 2 Cases

“…16,17 There are additional clinical factors in cardiovascular disorders, such as sex differences, that can also affect the clinical presentation. For example, women may present with a different intensity of chest pain symptoms, fatigue, and/or shortness of breath than would be typically expected of men.…”

“…17 The components of this prediction rule include (a) age/sex (female ≥ 65, male ≥ 55), (b) known clinical vascular disease, (c) pain symptoms exacerbated during exercise, (d) pain that is not reproduced with palpation, and (e) the patients assume that their chest pain is of a cardiac origin. The more components of the prediction rule that are present, the more likely that the patient has coronary artery disease, with 3/5 providing the best discrimination, having a sensitivity of 87.1%.…”

Acute coronary syndrome

“…Авторы исследования по определению валидности шкалы Marburg Heart Score 1 рекомендуют пользоваться этим инструментом в амбулаторной практике для формализованной оценки потребности пациен-та в неотложной помощи или в обследовании для верификации ИБС в ограниченные сроки. Разработчики шкалы Marburg Heart Score подчеркивают, что шкала не должна использо-ваться вместо врачебной оценки и осмотра, особенно если у пациента типичная симптома-тика ОКС или других угрожающих жизни со-стояний [16].…”

Ruling out coronary heart disease in primary care: external validation of a clinical prediction rule

“…The cut-off value used in the study for ruling out CHD was 3, as proposed by Bösner and colleagues. 5 The GPs were blinded to the results of the reference standard.…”

“…4,5 The Marburg Heart-Score (MHS) is based on five findings of the medical history and physical examination ( Table 1).…”