scholarly journals Chest pain for coronary heart disease in general practice: clinical judgement and a clinical decision rule

2015 ◽  
Vol 65 (640) ◽  
pp. e748-e753 ◽  
Author(s):  
Jörg Haasenritter ◽  
Norbert Donner-Banzhoff ◽  
Stefan Bösner
Keyword(s):  
Coronary Heart Disease ◽  
General Practice ◽  
Heart Disease ◽  
Chest Pain ◽  
Decision Rule ◽  
Clinical Decision ◽  
Clinical Judgement ◽  
Clinical Decision Rule

scholarly journals Chest pain in general practice: a systematic review of prediction rules

BMJ Open ◽  
2019 ◽  
Vol 9 (2) ◽  
pp. e027081 ◽  
Author(s):  
Ralf E Harskamp ◽  
Simone C Laeven ◽  
Jelle CL Himmelreich ◽  
Wim A M Lucassen ◽  
Henk C P M van Weert
Keyword(s):  
Systematic Review ◽  
General Practice ◽  
Chest Pain ◽  
Coronary Disease ◽  
Clinical Decision ◽  
Clinical Judgement ◽  
Predictive Values ◽  
Heart Score ◽  
Coronary Syndrome ◽  
Rule Out

ObjectiveTo identify and assess the performance of clinical decision rules (CDR) for chest pain in general practice.DesignSystematic review of diagnostic studies.Data sourcesMedline/Pubmed, Embase/Ovid, CINAHL/EBSCO and Google Scholar up to October 2018.Study selectionStudies that assessed CDRs for intermittent-type chest pain and for rule out of acute coronary syndrome (ACS) applicable in general practice, thus not relying on advanced laboratory, computer or diagnostic testing.Review methodsReviewers identified studies, extracted data and assessed the quality of the evidence (using Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2)), independently and in duplicate.ResultsEight studies comprising five CDRs met the inclusion criteria. Three CDRs are designed for rule out of coronary disease in intermittent-type chest pain (Gencer rule, Marburg Heart Score, INTERCHEST), and two for rule out of ACS (Grijseels rule, Bruins Slot rule). Studies that examined the Marburg Heart Score had the highest methodological quality with consistent sensitivity (86%–91%), specificity (61%–81%) and positive (23%–35%) and negative (97%–98%) predictive values (PPV and NPV). The diagnostic performance of Gencer (PPV: 20%–34%, NPV: 95%–99%) and INTERCHEST (PPV: 35%–43%, NPV: 96%–98%) appear comparable, but requires further validation. The Marburg Heart Score was more sensitive in detecting coronary disease than the clinical judgement of the general practitioner. The performance of CDRs that focused on rule out of ACS were: Grijseels rule (sensitivity: 91%, specificity: 37%, PPV: 57%, NPV: 82%) and Bruins Slot (sensitivity: 97%, specificity: 10%, PPV: 23%, NPV: 92%). Compared with clinical judgement, the Bruins Slot rule appeared to be safer than clinical judgement alone, but the study was limited in sample size.ConclusionsIn general practice, there is currently no clinical decision aid that can safely rule out ACS. For intermittent chest pain, several rules exist, of which the Marburg Heart Score has been most extensively tested and appears to outperform clinical judgement alone.

Validation of a clinical decision rule: chest X-ray in patients with chest pain and possible acute coronary syndrome

2014 ◽  
Vol 21 (4) ◽  
pp. 367-372 ◽  
Author(s):  
Romi Goldschlager ◽  
Hedley Roth ◽  
Jarryd Solomon ◽  
Scott Robson ◽  
Jessica Green ◽  
...  
Keyword(s):  
Acute Coronary Syndrome ◽  
Chest Pain ◽  
Decision Rule ◽  
Clinical Decision ◽  
Clinical Decision Rule ◽  
X Ray ◽  
Coronary Syndrome ◽  
Chest X Ray

scholarly journals Early health technology assessment of future clinical decision rule aided triage of patients presenting with acute chest pain in primary care

2017 ◽  
Vol 19 (02) ◽  
pp. 176-188 ◽  
Author(s):  
Robert T.A. Willemsen ◽  
Michelle M.A. Kip ◽  
Hendrik Koffijberg ◽  
Ron Kusters ◽  
Frank Buntinx ◽  
...  
Keyword(s):  
Primary Care ◽  
Chest Pain ◽  
The Netherlands ◽  
Decision Rule ◽  
Current Practice ◽  
Clinical Decision ◽  
Sensitivity Analyses ◽  
Pain Patient ◽  
Clinical Decision Rule ◽  
Referral Decisions

The objective of the paper is to estimate the number of patients presenting with chest pain suspected of acute coronary syndrome (ACS) in primary care and to calculate possible cost effects of a future clinical decision rule (CDR) incorporating a point-of-care test (PoCT) as compared with current practice. The annual incidence of chest pain, referrals and ACS in primary care was estimated based on a literature review and on a Dutch and Belgian registration study. A health economic model was developed to calculate the potential impact of a future CDR on costs and effects (ie, correct referral decisions), in several scenarios with varying correct referral decisions. One-way, two-way, and probabilistic sensitivity analyses were performed to test robustness of the model outcome to changes in input parameters. Annually, over one million patient contacts in primary care in the Netherlands concern chest pain. Currently, referral of eventual ACS negative patients (false positives, FPs) is estimated to cost €1,448 per FP patient, with total annual cost exceeding 165 million Euros in the Netherlands. Based on ‘international data’, at least a 29% reduction in FPs is required for the addition of a PoCT as part of a CDR to become cost-saving, and an additional €16 per chest pain patient (ie, 16.4 million Euros annually in the Netherlands) is saved for every further 10% relative decrease in FPs. Sensitivity analyses revealed that the model outcome was robust to changes in model inputs, with costs outcomes mainly driven by costs of FPs and costs of PoCT. If PoCT-aided triage of patients with chest pain in primary care could improve exclusion of ACS, this CDR could lead to a considerable reduction in annual healthcare costs as compared with current practice.

Effectiveness of Management of Suspected Deep Vein Thrombosis in General Practice Based on a Clinical Decision Rule Including a Point of Care D-dimer Test.

Blood ◽  
2007 ◽  
Vol 110 (11) ◽  
pp. 967-967
Author(s):  
Arina ten Cate-Hoek ◽  
Diane Toll ◽  
Eit Frits van der Velde ◽  
Arno Hoes ◽  
Harry Buller ◽  
...  
Keyword(s):  
General Practice ◽  
Deep Vein Thrombosis ◽  
Decision Rule ◽  
Point Of Care ◽  
Clinical Decision ◽  
Clinical Decision Rule ◽  
Vein Thrombosis ◽  
Deep Vein ◽  
D Dimer

Abstract Prior studies have evaluated the safety and effectiveness of a diagnostic work up based on combined use of a clinical decision rule and a D-dimer laboratory test in patients with suspected deep vein thrombosis in secondary care facilities. The overall outcome of these studies show that approximately 30% of additional objective evaluation can be avoided without compromising the safety, resulting in failure rates of less than 1%. The objective of our study was to assess the effectiveness of a modified algorithm using a dichotomized clinical decision rule including a point of care D-dimer test in patients suspected of deep vein thrombosis in primary care. The AMUSE study is a prospective cohort study of consecutive patients with clinically suspected acute deep vein thrombosis conducted in 400 general practices coordinated by 3 university affiliated centers in the Netherlands from March 2004 through January 2007. The study population of 1029 patients included 63% women. Patients were categorized as “deep vein thrombosis unlikely” or “deep vein thrombosis likely” using a dichotomized version of a for general practice adapted clinical decision rule based on the Wells rule. Patients classified as unlikely were excluded from further testing. All other patients underwent ultrasonography. Anticoagulants were withheld from patients classified as unlikely. All patients were followed up for 3 months. The main outcome measure was symptomatic or fatal venous thromboembolism (VTE) during 3 months follow-up. Deep vein thrombosis was classified as unlikely in 500 patients (48.6%), all of whom were not treated with anticoagulants; subsequent non fatal VTE occurred in 8 patients (1.6% [95 CI 0.7–3.1%]). In 500 patients categorized as likely, deep vein thrombosis was confirmed in 124 patients (24.8%), 3 patients did not receive objective testing (0.6%) and 373 patients were tested negative (74.6%). Two out of 4 patients not receiving objective testing had confirmed deep vein thrombosis in the 3 month follow-up period. In patients that tested negative 4 non fatal events occurred during the 3 month follow-up (1.1%). The algorithm was completed and allowed a management decision in 97.2% of patients. We conclude that this management strategy is both safe and highly effective in patients with suspected deep vein thrombosis in general practice. Its use is associated with low risk for subsequent fatal and nonfatal VTE and a further increase in the yield of objective diagnostic tests.

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