Steinhart Brian D, Levy Phillip, Vandenberghe Hilde, Moe Gordon, Yan Andrew T, Cohen Ashley, Thorpe Kevin E, McGowan Melissa, Mazer C David
Department of Emergency Medicine, St Michael's Hospital, Toronto, Ontario, Canada; Division of Emergency Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
Department of Emergency Medicine and Cardiovascular Research Institute, Wayne State University, Detroit, Michigan.
J Card Fail. 2017 Feb;23(2):145-152. doi: 10.1016/j.cardfail.2016.08.007. Epub 2016 Aug 24.
Diagnosing acute heart failure (AHF) in undifferentiated dyspneic emergency department (ED) patients can be challenging. We prospectively studied a validated diagnostic prediction model for AHF that uses patient age, clinician pretest probability for AHF, and N-terminal pro-B-type natriuretic peptide (NT-proBNP) as a continuous value to determine its utility and performance.
This was a multicenter randomized controlled trial of undifferentiated dyspneic patients with an indeterminate pretest probability of AHF as assessed by the treating emergency physician (EP). After recording its components, the calculated model results with validated treatment threshold guidelines were provided to EPs for patients randomized to the intervention arm. Final diagnoses with the use of 60-day follow-up information were adjudicated by 2 independent cardiologists. The primary outcomes were accuracy of the model and of physician diagnosis comparing intervention and standard care arms. A total of 197 patients were randomized and had outcome data recorded; 41% were determined to have had heart failure. Final EP diagnostic accuracy was 76% (sensitivity 68.2%, specificity 83.9%) with no significant difference between exposed versus blinded arms (accuracy 77% vs 74%; P = .77). Area under the model receiver operating characteristic curve was 0.93. Using the model treatment thresholds would have redirected 48% of patients with 95% accuracy.
This study prospectively validated the diagnostic accuracy of our AHF model in a significant proportion of indeterminate dyspneic ED patients, but provision of this information did not improveEP diagnostic accuracy. Future studies should determine how such a clinical prediction tool could be effectively integrated into routine practice and improve early management of suspected AHF patients in the ED.
在未分化的急诊呼吸困难患者中诊断急性心力衰竭（AHF）具有挑战性。我们前瞻性地研究了一种经过验证的AHF诊断预测模型，该模型使用患者年龄、临床医生对AHF的预测试概率以及N末端B型利钠肽原（NT-proBNP）作为连续值来确定其效用和性能。
这是一项针对未分化呼吸困难患者的多中心随机对照试验，这些患者的AHF预测试概率由急诊医生（EP）评估为不确定。记录其组成部分后，将根据经过验证的治疗阈值指南计算出的模型结果提供给随机分配到干预组的患者的EP。使用60天随访信息得出的最终诊断由2名独立的心脏病专家判定。主要结局是比较干预组和标准治疗组时模型和医生诊断的准确性。共有197名患者被随机分组并记录了结局数据；41%的患者被确定患有心力衰竭。最终EP诊断准确性为76%（敏感性68.2%，特异性83.9%），暴露组与盲法组之间无显著差异（准确性77%对74%；P = 0.77）。模型受试者操作特征曲线下面积为0.93。使用模型治疗阈值可使48%的患者得到重新定向，准确性为95%。
本研究前瞻性地验证了我们的AHF模型在很大一部分不确定的急诊呼吸困难患者中的诊断准确性，但提供此信息并未提高EP诊断准确性。未来的研究应确定如何将这种临床预测工具有效地整合到常规实践中，并改善急诊疑似AHF患者的早期管理。
