A Clinical Decision Rule to Identify Emergency Department Patients at Low Risk for Acute Coronary Syndrome Who Do Not Need Objective Coronary Artery Disease Testing: The No Objective Testing Rule

Greenslade, Jaimi H., Parsonage, William, Than, Martin, Scott, Adam, Aldous, Sally, Pickering, John W., Hammett, Christopher J. and Cullen, Louise (2015) A Clinical Decision Rule to Identify Emergency Department Patients at Low Risk for Acute Coronary Syndrome Who Do Not Need Objective Coronary Artery Disease Testing: The No Objective Testing Rule. Annals of Emergency Medicine, 67 4: 478-489.e2. doi:10.1016/j.annemergmed.2015.08.006


Author Greenslade, Jaimi H.
Parsonage, William
Than, Martin
Scott, Adam
Aldous, Sally
Pickering, John W.
Hammett, Christopher J.
Cullen, Louise
Title A Clinical Decision Rule to Identify Emergency Department Patients at Low Risk for Acute Coronary Syndrome Who Do Not Need Objective Coronary Artery Disease Testing: The No Objective Testing Rule
Journal name Annals of Emergency Medicine   Check publisher's open access policy
ISSN 1097-6760
0196-0644
Publication date 2015-09-10
Year available 2015
Sub-type Article (original research)
DOI 10.1016/j.annemergmed.2015.08.006
Open Access Status Not Open Access
Volume 67
Issue 4
Start page 478
End page 489.e2
Total pages 14
Place of publication Philadelphia, Pennsylvania, United States
Publisher Mosby
Collection year 2016
Language eng
Formatted abstract
Study objective: We derive a clinical decision rule for ongoing investigation of patients who present to the emergency department (ED) with chest pain. The rule identifies patients who are at low risk of acute coronary syndrome and could be discharged without further cardiac testing.

Methods: This was a prospective observational study of 2,396 patients who presented to 2 EDs with chest pain suggestive of acute coronary syndrome and had normal troponin and ECG results 2 hours after presentation. Research nurses collected clinical data on presentation, and the primary endpoint was diagnosis of acute coronary syndrome within 30 days of presentation to the ED. Logistic regression analyses were conducted on 50 bootstrapped samples to identify predictors of acute coronary syndrome. A rule was derived and diagnostic accuracy statistics were computed.

Results: Acute coronary syndrome was diagnosed in 126 (5.3%) patients. Regression analyses identified the following predictors of acute coronary syndrome: cardiac risk factors, age, sex, previous myocardial infarction, or coronary artery disease and nitrate use. A rule was derived that identified 753 low-risk patients (31.4%), with sensitivity 97.6% (95% confidence interval [CI] 93.2% to 99.5%), negative predictive value 99.6% (95% CI 98.8% to 99.9%), specificity 33.0% (95% CI 31.1% to 35.0%), and positive predictive value 7.5% (95% CI 6.3% to 8.9%) for acute coronary syndrome. This was referred to as the no objective testing rule.

Conclusion: We have derived a clinical decision rule for chest pain patients with negative early cardiac biomarker and ECG testing results that identifies 31% at low risk and who may not require objective testing for coronary artery disease. A prospective trial is required to confirm these findings.
Q-Index Code C1
Q-Index Status Confirmed Code
Institutional Status UQ

Document type: Journal Article
Sub-type: Article (original research)
Collections: Official 2016 Collection
School of Medicine Publications
 
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