Reilly B, Durairaj L, Husain S, Acob C, Evans A, Hu T C, Das K, McNutt R
Department of Medicine, Cook County Hospital and Rush Medical College, Chicago, IL 60612, USA.
Am J Med. 1999 Mar;106(3):285-91. doi: 10.1016/s0002-9343(99)00024-8.
To evaluate the performance of a previously validated prediction rule for patients presenting to the emergency department with chest pain and the potential impact of the rule on triage decisions.
In a prospective cohort study, physician investigators interviewed consecutive patients admitted for suspected acute ischemic heart disease (n = 207) by emergency department attending physicians who had not used the prediction rule. We measured the accuracy of the rule in predicting cardiac complications in these patients, and compared actual triage decisions with those that might have been recommended by use of the prediction rule. We also measured comorbid illnesses among patients stratified as very low risk by the prediction rule, as well as the effect of standardizing the definition of unstable angina and interpretation of electrocardiograms (ECG) on the rule's sensitivity and specificity.
Overall, the rate of major cardiac complications (4.3%) was similar to that reported in the original study (3.6%). The prediction rule performed well in predicting these complications in our patients (area under receiver operating characteristic curve 0.84 versus 0.80 in the original study; difference 0.04, 95% confidence interval [CI] -0.07, 0.14). Standardized definitions of unstable angina and interpretation of ECGs improved the specificity of the prediction rule in predicting complications (55% versus 47%; difference 8%, 95% CI 1.5%, 13.7%). The prediction rule recommended admission to telemetry units in 65 fewer patients than actually occurred (31% of the entire cohort). None of these patients had major complications. A substantial minority of "very low risk" patients (27%) had comorbid illnesses requiring inpatient treatment.
This independent validation of the prediction rule suggests that it can improve triage decisions for patients admitted with suspected acute ischemic heart disease. Additional studies are needed to test prospectively the performance of the prediction rule in actual decision making, its acceptance by clinicians, and its cost effectiveness.
评估一项先前经验证的预测规则对于因胸痛就诊于急诊科患者的性能，以及该规则对分诊决策的潜在影响。
在一项前瞻性队列研究中，医师研究者对由未使用该预测规则的急诊科主治医师收治的疑似急性缺血性心脏病患者（n = 207）进行连续访谈。我们测量了该规则在预测这些患者心脏并发症方面的准确性，并将实际分诊决策与使用该预测规则可能推荐的决策进行比较。我们还测量了根据预测规则被分层为极低风险患者中的共病情况，以及不稳定型心绞痛定义标准化和心电图（ECG）解读对该规则敏感性和特异性的影响。
总体而言，主要心脏并发症发生率（4.3%）与原始研究报告的发生率（3.6%）相似。该预测规则在预测我们患者的这些并发症方面表现良好（受试者操作特征曲线下面积为0.84，而原始研究中为0.80；差异为0.04，95%置信区间[CI]为 -0.07，0.14）。不稳定型心绞痛的标准化定义和心电图解读提高了预测规则在预测并发症方面的特异性（55%对47%；差异为8%，95%CI为1.5%，13.7%）。该预测规则推荐入住遥测病房的患者比实际发生的少65例（占整个队列的31%）。这些患者均无主要并发症。相当一部分“极低风险”患者（27%）患有需要住院治疗的共病。
该预测规则的这项独立验证表明，它可以改善疑似急性缺血性心脏病入院患者的分诊决策。需要进一步研究前瞻性地测试该预测规则在实际决策中的性能、临床医生对其的接受程度及其成本效益。
