Napoli Anthony M
From the Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI.
Crit Pathw Cardiol. 2015 Dec;14(4):154-6. doi: 10.1097/HPC.0000000000000056.
Cardiology consensus guidelines recommend use of the Diamond & Forrester (D&F) score in augmenting the decision to pursue stress testing. We have recently shown that it may have value in safely reducing stress utilization in an emergency department chest pain unit (CPU). However, full application necessitates demonstration of a good inter-rater reliability of the D&F score in the CPU setting. We hypothesized that D&F pretest probability would have good inter-rater reliability in CPU patients.
This was a chart review of randomly selected patients from a previously collected prospective observational trial of admitted CPU patients in a large-volume academic urban emergency department. Inclusion criteria were: age>18 years, American Heart Association low/intermediate risk, nondynamic electrocardiograms, and normal initial troponin I. Exclusion criteria were: age>75 years with coronary artery disease. A D&F score for likelihood of coronary artery disease was calculated on each patient by 2 trained chart abstractors using a standardized data abstraction instrument. Abstractors were trained to specifically categorize presenting symptoms as fitting 1 of 3 types of chest pain symptoms: nonanginal, atypical, or anginal based on previously published prespecified criteria. Approximately 20% of charts in a CPU registry were abstracted by 2 chart abstractors who were blind to each other's categorization, the patient outcomes, and the study hypothesis. The primary outcome was the kappa statistic for agreement between the 2 raters.
The charts of 705 random patients were reviewed. The mean age was 55.1±11.8 years, 52% were female. Forty four percentage of patients received stress testing, and 2.4% of patients had acute coronary syndrome. The mean D&F score was 39±24. There was good inter-rater agreement of chest pain characteristics (κ=0.77, 95% confidence interval, 0.72-0.81; P<0.01).
This study supports the use of the D&F score as a reliable indicator of pretest probability in CPU patients by demonstrating that there is good inter-rater reliability. Prospective validation is necessary at the point of patient assessment, in conjunction with application of the D&F score to augment stress utilization decision making.
心脏病学共识指南建议使用钻石与弗雷斯特（D&F）评分来辅助决定是否进行负荷试验。我们最近发现，它可能有助于安全地减少急诊科胸痛单元（CPU）中负荷试验的使用。然而，要全面应用该评分，必须证明其在CPU环境下具有良好的评分者间信度。我们假设D&F预测试概率在CPU患者中具有良好的评分者间信度。
这是一项对来自之前在一家大型学术性城市急诊科收集的CPU住院患者前瞻性观察性试验中随机选择的患者的病历回顾。纳入标准为：年龄>18岁，美国心脏协会低/中风险，非动态心电图，以及初始肌钙蛋白I正常。排除标准为：年龄>75岁且患有冠状动脉疾病。两名经过培训的病历摘要员使用标准化的数据摘要工具为每位患者计算冠状动脉疾病可能性的D&F评分。摘要员经过培训，根据先前公布的预先设定标准，将出现的症状具体分类为符合三种胸痛症状类型之一：非心绞痛型、非典型心绞痛型或心绞痛型。CPU登记处约20%的病历由两名彼此不知道对方分类、患者结局和研究假设的病历摘要员进行摘要。主要结局是两名评分者之间一致性的kappa统计量。
回顾了705例随机患者的病历。平均年龄为55.1±11.8岁，52%为女性。44%的患者接受了负荷试验，2.4%的患者患有急性冠状动脉综合征。平均D&F评分为39±24。胸痛特征在评分者间具有良好的一致性（κ=0.77，95%置信区间，0.72 - 0.81；P<0.01）。
本研究通过证明评分者间具有良好的信度，支持将D&F评分用作CPU患者预测试概率的可靠指标。在患者评估时，结合应用D&F评分以辅助负荷试验使用决策，进行前瞻性验证是必要的。
