Can emergency physicians 'rule in' and 'rule out' acute myocardial infarction with clinical judgement?
Richard Body1, Gary Cook2, Gillian Burrows2
1The University of Manchester, Manchester, UK Central Manchester University Hospitals Foundation NHS Trust, Manchester Academic Health Science Centre, Manchester, UK.
Insights
Emergency physician gestalt combined with ECG and troponin testing achieves 100% sensitivity for diagnosing acute myocardial infarction (AMI), potentially reducing hospital admissions for suspected cardiac chest pain.
Area of Science:
- Emergency Medicine
- Cardiology
- Diagnostic Accuracy
Background:
- Suspected cardiac chest pain is a common emergency department (ED) presentation.
- Accurate and timely diagnosis of acute myocardial infarction (AMI) is critical.
- Current diagnostic strategies involve clinical gestalt, electrocardiogram (ECG), and troponin testing.
Purpose of the Study:
- To evaluate the diagnostic accuracy of emergency physician gestalt for suspected cardiac chest pain.
- To assess the combined diagnostic utility of gestalt, initial troponin levels, and ECG findings.
- To determine if a combined approach can safely rule out acute coronary syndrome (ACS).
Main Methods:
- Prospective study of ED patients with suspected cardiac chest pain.
- Clinician gestalt recorded on a five-point Likert scale, blinded to outcome.
- Initial troponin T and high-sensitivity troponin T (hs-cTnT) measured; troponin testing at least 12 hours post-symptoms.
- Primary outcome: diagnosis of AMI.
Main Results:
- 81 of 458 patients (17.7%) had AMI.
- Gestalt alone had an area under the curve of 0.76 for AMI.
- Combining gestalt with initial troponin and ECG achieved 100% sensitivity for AMI.
- This combined approach could have allowed 41.7% of patients to be discharged immediately using hs-cTnT.
Conclusions:
- Emergency physician gestalt alone is insufficient to rule in or out ACS.
- Combining gestalt with initial ECG and troponin levels provides 100% sensitivity for AMI.
- This strategy may reduce unnecessary hospital admissions for suspected ACS.
- Prospective validation is needed before clinical implementation.
Objective:
To determine the diagnostic accuracy of emergency physician gestalt in emergency department (ED) patients with suspected cardiac chest pain, both alone and in combination with initial troponin level and ECG findings.
Methods:
We prospectively included patients presenting to the ED with suspected cardiac chest pain. Clinicians recorded their 'gestalt' at the time of presentation using a five-point Likert scale, blinded to outcome. Troponin T and high-sensitivity troponin T (hs-cTnT; both Roche Diagnostics Elecsys) levels were measured in admission blood samples. All patients underwent troponin testing at least 12 h after peak symptoms. The primary outcome was acute myocardial infarction (AMI).
Results:
458 patients were included in this study, 81 (17.7%) of whom had AMI. Clinician gestalt alone had an area under the receiver operating characteristic curve of 0.76 (95% CI 0.70 to 0.82) for AMI. Immediately discharging patients with normal initial troponin and ECG in whom the clinician felt the diagnosis was 'probably not' or 'definitely not' acute coronary syndrome (ACS) would have avoided admission for 23.1% (95% CI 19% to 28%) patients with 100% sensitivity (95% CI 95.6% to 100%). With hs-cTnT, 100% sensitivity could have been achieved even if only patients with 'probable' or 'definite' ACS were investigated further, which would have allowed 41.7% patients to be discharged immediately.
Conclusions:
Gestalt alone cannot be used to 'rule in' or 'rule out' ACS. By combining clinician gestalt with the admission ECG and troponin level, we found 100% sensitivity without the need for serial troponin testing. These findings have the potential to reduce unnecessary hospital admissions for suspected ACS but must be prospectively validated before considering clinical implementation.
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