Accuracy of gestalt perception of acute chest pain in predicting coronary artery disease

Abstract

AIMTo test accuracy and reproducibility of gestalt to predict obstructive coronary artery disease (CAD) in patients with acute chest pain.METHODSWe studied individuals who were consecutively admitted to our Chest Pain Unit. At admission, investigators performed a standardized interview and recorded 14 chest pain features. Based on these features, a cardiologist who was blind to other clinical characteristics made unstructured judgment of CAD probability, both numerically and categorically. As the reference standard for testing the accuracy of gestalt, angiography was required to rule-in CAD, while either angiography or non-invasive test could be used to rule-out. In order to assess reproducibility, a second cardiologist did the same procedure.RESULTSIn a sample of 330 patients, the prevalence of obstructive CAD was 48%. Gestalt’s numerical probability was associated with CAD, but the area under the curve of 0.61 (95%CI: 0.55-0.67) indicated low level of accuracy. Accordingly, categorical definition of typical chest pain had a sensitivity of 48% (95%CI: 40%-55%) and specificity of 66% (95%CI: 59%-73%), yielding a negligible positive likelihood ratio of 1.4 (95%CI: 0.65-2.0) and negative likelihood ratio of 0.79 (95%CI: 0.62-1.02). Agreement between the two cardiologists was poor in the numerical classification (95% limits of agreement = -71% to 51%) and categorical definition of typical pain (Kappa = 0.29; 95%CI: 0.21-0.37).CONCLUSIONClinical judgment based on a combination of chest pain features is neither accurate nor reproducible in predicting obstructive CAD in the acute setting.

Diagnostic Performance of Emergency Physician Gestalt for Predicting Acute Appendicitis in Patients Age 5 to 20 Years

“…For example, the presence of RLQ maximal tenderness was dramatically higher in the 90% to 100% gestalt category compared with the 1% to 10% gestalt category (p < 0.001), while pain <24 hours was not significantly associated with increased gestalt (p = 0.99). Performance of physician gestalt is known to vary in a condition‐specific manner, and it is possible that pediatric appendicitis is associated with better performance due to the presence of trademark physical examination findings such as RLQ tenderness . Interestingly, 57.6% of patients in the lowest gestalt subgroup had pain <24 hours, accounting for 81% of appendicitis cases in the low‐gestalt cohort.…”

Perioperative cardiac investigations for chest pain after parathyroidectomy rarely yield a cardiac diagnosis

“…Chest pain in isolation has not been proven specific enough to prompt further cardiac investigations. 2 – 4 A study of experienced cardiologists’ abilities to detect coronary artery disease showed that even with decades of experience, a clinician’s gestalt has a low level of accuracy, with “typical chest pain” yielding negligible positive and negative likelihood ratios. The study further reported poor interclinician agreement in the definition of “typical chest pain.” 4 …”