Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria.
Int J Clin Pract. 2020 Aug;74(8):e13526. doi: 10.1111/ijcp.13526. Epub 2020 May 22.
A considerable proportion of patients with angina-like symptoms in an emergency department have very low pretest probability for acute myocardial infarction (AMI). Numerous algorithms exist for the exclusion of AMI, usually including laboratory tests. We aimed to investigate whether patients with very low risk can safely be identified by ECG and clinical information without biomarker testing, contributing to saving time and costs.
Prospective diagnostic test accuracy study. We included all consecutive patients presenting with angina at the department of emergency medicine of a tertiary care hospital during a 1-year period. Using clinical information without biomarker testing and ECG, the "Mini-GRACE score," based on the well-established GRACE-score without using laboratory parameters was calculated. In a cohort design we compared the index test Mini-GRACE to AMI as reference standard in the final diagnosis using standard measures of diagnostic test accuracy.
We included 2755 patients (44% female, age 44 ± 17 years). AMI was diagnosed in 103 (4%) patients, among those 44% with STEMI. Overall 2562 patients (93%) had a negative "Mini-GRACE," four (0.2%) of these patients had myocardial infarction, and this results in a sensitivity of 96.1% (95% CI 90.4%-98.9%), specificity 96.5% (95.7%-97.1%), positive predictive value 51.3% (46.3%-56.3%) and negative predictive value 99.8% (99.6%-99.9%). Model performance according to C statistic (0.90) and Brier score (0.0045) was excellent. In rule-out patients 30-day mortality was 0.3% and 1-year mortality was 0.8%.
Patients with very low risk of AMI can be identified with high certainty using clinical information without biomarker testing and ECG. Cardiac biomarkers might be avoided in such cases, potentially leading to a significant cost reduction.
在急诊科出现心绞痛样症状的患者中，相当一部分发生急性心肌梗死（AMI）的可能性非常低。目前有许多用于排除 AMI 的算法，通常包括实验室检查。我们旨在研究是否可以通过心电图和临床信息而无需生物标志物检测来安全识别低风险患者，从而有助于节省时间和成本。
前瞻性诊断准确性研究。我们纳入了在一家三级医院急诊科就诊的所有连续出现心绞痛的患者，在一年期间内。使用不包含生物标志物检测和心电图的临床信息，基于未使用实验室参数的成熟 GRACE 评分，计算出“Mini-GRACE 评分”。我们采用队列设计，比较指数测试 Mini-GRACE 与最终诊断的 AMI 作为参考标准，使用诊断准确性的标准指标。
我们纳入了 2755 例患者（44%为女性，年龄 44 ± 17 岁）。103 例（4%）患者被诊断为 AMI，其中 44%为 ST 段抬高型心肌梗死。总体而言，2562 例（93%）患者的“Mini-GRACE”结果为阴性，其中 4 例（0.2%）患者发生心肌梗死，这使得灵敏度为 96.1%（95%CI 90.4%-98.9%），特异性为 96.5%（95.7%-97.1%），阳性预测值为 51.3%（46.3%-56.3%），阴性预测值为 99.8%（99.6%-99.9%）。根据 C 统计量（0.90）和 Brier 评分（0.0045），模型性能非常好。在排除患者中，30 天死亡率为 0.3%，1 年死亡率为 0.8%。
使用不包含生物标志物检测和心电图的临床信息，能够非常确定地识别出发生 AMI 的风险非常低的患者。在这种情况下，可以避免进行心脏生物标志物检测，可能会显著降低成本。
