Hostname: page-component-5c6d5d7d68-vt8vv Total loading time: 0.001 Render date: 2024-08-30T17:15:38.688Z Has data issue: false hasContentIssue false
  • English
  • Français

Derivation of a clinical decision rule for chest radiography in emergency department patients with chest pain and possible acute coronary syndrome

Published online by Cambridge University Press:  21 May 2015

Erik P. Hess ,
Jeffrey J. Perry ,
Pam Ladouceur ,
George A. Wells  and
Ian G. Stiell
Erik P. Hess*
Affiliation:
Department of Emergency Medicine, Mayo Clinic College of Medicine, Rochester, Minn.
Jeffrey J. Perry
Affiliation:
Department of Emergency Medicine, University of Ottawa, Ottawa, Ont. Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ont.
Pam Ladouceur
Affiliation:
Department of Emergency Medicine, University of Ottawa, Ottawa, Ont.
George A. Wells
Affiliation:
Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ont.
Ian G. Stiell
Affiliation:
Department of Emergency Medicine, University of Ottawa, Ottawa, Ont. Department of Epidemiology and Community Medicine, University of Ottawa, Ottawa, Ont.
*
Department of Emergency Medicine, Division of Emergency Medicine Research, Mayo Clinic College of Medicine, 200 First St. SW, Rochester MN 55905; hess.erik@mayo.edu

Abstract

Core share and HTML view are not available for this content. However, as you have access to this content, a full PDF is available via the ‘Save PDF’ action button.
Objective:

We derived a clinical decision rule to determine which emergency department (ED) patients with chest pain and possible acute coronary syndrome (ACS) require chest radiography.

Methods:

We prospectively enrolled patients over 24 years of age with a primary complaint of chest pain and possible ACS over a 6-month period. Emergency physicians completed standardized clinical assessments and ordered chest radiographs as appropriate. Two blinded investigators independently classified chest radiographs as “normal,” “abnormal not requiring intervention” and “abnormal requiring intervention,” based on review of the radiology report and the medical record. The primary outcome was abnormality of chest radiographs requiring acute intervention. Analyses included interrater reliability assessment (with κ statistics), univariate analyses and recursive partitioning.

Results:

We enrolled 529 patients during the study period between Jul. 1, 2007, and Dec. 31, 2007. Patients had a mean age of 59.9 years, 60.3% were male, 4.0% had a history of congestive heart failure and 21.9% had a history of acute myocardial infarction. Only 2.1% (95% confidence interval [CI] 1.1%–3.8%) of patients had radiographic abnormality of the chest requiring acute intervention. The κ statistic for chest radiograph classification was 0.81 (95% CI 0.66–0.95). We derived the following rule: patients can forgo chest radiography if they have no history of congestive heart failure, no history of smoking and no abnormalities on lung auscultation. The rule was 100% sensitive (95% CI 32.0%–10.4%) and 36.1% specific (95% CI 32.0%–40.4%).

Conclusion:

This rule has potential to reduce health care costs and enhance ED patient flow. It requires validation in an independent patient population before introduction into clinical practice.

Keywords

diagnosisradiographyemergency medical servicesacute coronary syndromemyocardial infarctionunstable angina
Type
Original Research • Recherche originale
Information
Canadian Journal of Emergency Medicine , Volume 12 , Issue 2 , March 2010 , pp. 128 - 134
Copyright
Copyright © Canadian Association of Emergency Physicians 2010

References

REFERENCES

1.Nawar, EW, Niska, RW, Xu, J. National Hospital Ambulatory Medical Care Survey: 2005 emergency department summary. Adv Data 2007Jun 29:1–32.Google Scholar
2.Zimetbaum, PJ, Josephson, ME. Use of the electrocardiogram in acute myocardial infarction. N Engl J Med 2003;348:933–40.Google Scholar
3.Jaffe, AS, Babuin, L, Apple, FS. Biomarkers in acute cardiac disease: the present and the future. J Am Coll Cardiol 2006;48:1–11.CrossRefGoogle ScholarPubMed
4.Stiell, IG, Wells, GA, Vandemheen, KL, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA 2001;286:1841–8.Google Scholar
5.Stiell, IG, Wells, GA, Vandemheen, K, et al. The Canadian CT Head Rule for patients with minor head injury. Lancet 2001;357:1391–6.CrossRefGoogle ScholarPubMed
6.Laupacis, A, Sekar, N, Stiell, IG. Clinical prediction rules. A review and suggested modifications of methodological standards. JAMA 1997;277:488–94.CrossRefGoogle ScholarPubMed
7.McGinn, TG, Guyatt, GH, Wyer, PC, et al.; Evidence-Based Medicine Working Group. Users’ guides to the medical literature: XXII: How to use articles about clinical decision rules. JAMA 2000;284:79–84.CrossRefGoogle Scholar
8.Hess, EP, Thiruganasambandamoorthy, V, Wells, GA, et al. Diagnostic accuracy of clinical prediction rules to exclude acute coronary syndrome in the emergency department setting: a systematic review. CJEM 2008;10:373–82.CrossRefGoogle ScholarPubMed
9.Ciampi, A, Thiffault, J, Nakache, JP, et al. Stratification by step-wise regression, correspondence analysis and recursive partition: a comparison of three methods of analysis for survival data with covariates. Comput Stat Data Anal 1986;4:185–204.CrossRefGoogle Scholar
10.Ciampi, A, Hogg, SA, McKinney, S, et al. RECPAM: a computer program for recursive partition and amalgamation for censored suvival data and other situations frequently occurring in biostatistics. I. Methods and program features. Comput Methods Programs Biomed 1988;26:239–56.Google Scholar
11.Friedman, JH. A recursive partitioning decision rule for non-parametric classification. IEE. Trans.Comput. 1977;26:404–8.CrossRefGoogle Scholar
12.Hubbell, FA, Ziemba, SE, Fine, MJ, et al. The value of baseline chest radiograph reports in the care of elderly patients in an emergency department. Am J Med Sci 1993;305:145–9.CrossRefGoogle ScholarPubMed
13.Birkemeier, KL, Nipper, ML, Williams, JM. Is the chest X-ray an appropriate screening exam for ER patients with AMS? EmergRadiol. 2008;15:421–5.Google ScholarPubMed
14.Stiell, IG, Wells, GA. Methodologic standards for the development of clinical decision rules in emergency medicine. Ann Emerg Med 1999;33:437–47.CrossRefGoogle ScholarPubMed