Leiden University Medical Center, Department of Public Health and Primary Care, Leiden, The Netherlands
Amsterdam UMC, University of Amsterdam, Academic Medical Center, Departments of General Practice and Public and Occupational Health, Amsterdam Public Health, Amsterdam, The Netherlands.
Ann Fam Med. 2024 Sep-Oct;22(5):426-436. doi: 10.1370/afm.3141.
Chest pain frequently poses a diagnostic challenge for general practitioners (GPs). Utilizing risk stratification tools might help GPs to rule out acute coronary syndrome (ACS) and make appropriate referral decisions. We conducted a systematic review of studies evaluating risk stratification tools for chest pain in primary care settings, both with and without troponin assays. Our aims were to assess the performance of tools for ruling out ACS and to provide a comprehensive review of the current evidence.
We searched PubMed and Embase for articles up to October 9, 2023 concerning adult patients with acute chest pain in primary care settings, for whom risk stratification tools (clinical decision rules [CDRs] and/or single biomarker tests) were used. To identify eligible studies, a combination of active learning and backward snowballing was applied. Screening, data extraction, and quality assessment (following the Quality Assessment of Diagnostic Accuracy Studies-2 tool) were performed independently by 2 researchers.
Of the 1,204 studies screened, 14 were included in the final review. Nine studies validated 7 different CDRs without troponin. Sensitivities ranged from 75.0% to 97.0%, and negative predictive values (NPV) ranged from 82.4% to 99.7%. None of the CDRs outperformed the unaided judgment of GP's. Five studies reported on strategies using troponin measurements. Studies using high-sensitivity troponin showed highest diagnostic accuracy with sensitivity 83.3% to 100% and NPV 98.8% to 100%.
Clinical decision rules without troponin and the use of conventional troponin showed insufficient sensitivity to rule out ACS in primary care and are not recommended as standalone tools. High-sensitivity troponin strategies are promising, but studies are limited. Further prospective validation in primary care is needed before implementation.
胸痛经常给全科医生（GP）带来诊断挑战。利用风险分层工具可能有助于 GP 排除急性冠状动脉综合征（ACS）并做出适当的转诊决策。我们对评估初级保健环境中胸痛风险分层工具的研究进行了系统评价，包括使用和不使用肌钙蛋白检测的研究。我们的目的是评估用于排除 ACS 的工具的性能，并对当前证据进行全面综述。
我们在 PubMed 和 Embase 上搜索了截至 2023 年 10 月 9 日的文章，涉及初级保健环境中急性胸痛的成年患者，这些患者使用了风险分层工具（临床决策规则[CDR]和/或单一生物标志物检测）。为了确定合格的研究，我们采用了主动学习和回溯雪球的组合方法。由两名研究人员独立进行筛选、数据提取和质量评估（采用诊断准确性研究的质量评估-2 工具）。
在筛选的 1204 篇文章中，有 14 篇被纳入最终综述。9 项研究验证了 7 种不同的无肌钙蛋白 CDR。敏感性范围为 75.0%至 97.0%，阴性预测值（NPV）范围为 82.4%至 99.7%。没有一种 CDR 优于 GP 的单纯判断。5 项研究报告了使用肌钙蛋白测量的策略。使用高敏肌钙蛋白的研究显示出最高的诊断准确性，敏感性为 83.3%至 100%，NPV 为 98.8%至 100%。
无肌钙蛋白的 CDR 和常规肌钙蛋白的使用都不足以在初级保健中排除 ACS，因此不推荐作为独立工具。高敏肌钙蛋白策略很有前景，但研究有限。在实施之前，需要在初级保健中进行进一步的前瞻性验证。
