Center for Healthcare Delivery Innovation, Minneapolis Heart Institute, Minneapolis, Minnesota, USA.
Allina Health, Minneapolis, Minnesota, USA.
Heart. 2019 Jan;105(2):112-116. doi: 10.1136/heartjnl-2018-313269. Epub 2018 Jun 20.
To determine the implications of applying guideline-recommended definitions of aortic stenosis to echocardiographic data captured in routine clinical care.
Retrospective observational study of 213 174 patients who underwent transthoracic echocardiographic imaging within Allina Health between January 2013 and October 2017. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of echocardiographic measures for severe aortic stenosis were determined relative to the documented interpretation of severe aortic stenosis.
Among 77 067 patients with complete assessment of the aortic valve, 1219 (1.6%) patients were categorised as having severe aortic stenosis by the echocardiographic reader. Relative to the documented interpretation, aortic valve area (AVA) as a measure of severe aortic stenosis had the high sensitivity (94.1%) but a low positive predictive value (37.5%). Aortic valve peak velocity and mean gradient were specific (>99%), but less sensitive (<70%). A measure incorporating peak velocity, mean gradient and dimensionless index (either by velocity time integral or peak velocity ratio) achieved a balance of sensitivity (92%) and specificity (99%) with little detriment in accuracy relative to peak velocity and mean gradient alone (98.9% vs 99.3%). Using all available data, the proportion of patients whose echocardiogram could be assessed for aortic stenosis was 79.8% as compared with 52.7% by documented interpretation alone.
A measure that used dimensionless index in place of AVA addressed discrepancies between quantitative echocardiographic data and the documented interpretation of severe aortic stenosis. These findings highlight the importance of understanding the limitations of clinical data as it relates to quality improvement efforts and pragmatic research design.
确定将指南推荐的主动脉瓣狭窄定义应用于常规临床护理中获取的超声心动图数据的意义。
这是一项回顾性观察研究，纳入了 2013 年 1 月至 2017 年 10 月期间在 Allina Health 接受经胸超声心动图成像的 213174 例患者。根据严重主动脉瓣狭窄的记录解读，确定超声心动图测量严重主动脉瓣狭窄的敏感性、特异性、阳性预测值、阴性预测值和准确性。
在 77067 例完成主动脉瓣全面评估的患者中，1219 例（1.6%）患者被超声心动图阅读器归类为严重主动脉瓣狭窄。与记录的解读相比，作为严重主动脉瓣狭窄的测量方法，主动脉瓣瓣口面积（AVA）具有较高的敏感性（94.1%），但阳性预测值较低（37.5%）。主动脉瓣峰值速度和平均梯度具有较高的特异性（>99%），但敏感性较低（<70%）。一种纳入峰值速度、平均梯度和无量纲指数（通过速度时间积分或峰值速度比）的测量方法，在不降低准确性（98.9%对 99.3%）的情况下，达到了敏感性（92%）和特异性（99%）的平衡。与仅使用记录的解读相比，使用所有可用数据可评估超声心动图是否存在主动脉瓣狭窄的患者比例为 79.8%，而仅使用记录的解读为 52.7%。
使用无量纲指数替代 AVA 的测量方法解决了定量超声心动图数据与严重主动脉瓣狭窄的记录解读之间的差异。这些发现强调了理解临床数据局限性的重要性，这与质量改进工作和实用研究设计有关。
