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

Abstract

BackgroundThe Marburg Heart Score (MHS) is a simple, valid, and robust clinical decision rule assisting GPs in ruling out coronary heart disease (CHD) in patients presenting with chest pain. AimTo investigate whether using the rule adds to the GP's clinical judgement. Design and settingA comparative diagnostic accuracy study was conducted using data from 832 consecutive patients with chest pain in general practice. MethodThree diagnostic strategies were defined using the MHS: diagnosis based solely on the MHS; using the MHS as a triage test; and GP's clinical judgement aided by the MHS. Their accuracy was compared with the GPs' unaided clinical judgement. ResultsSensitivity and specificity of the GPs' unaided clinical judgement was 82.9% (95% confidence interval [CI] = 72.4 to 89.9) and 61.0% (95% CI = 56.7 to 65.2), respectively. In comparison, the sensitivity of the MHS was higher (difference 8.5%, 95% CI = -2.4 to 19.6) and the specificity was similar (difference -0.4%, 95% CI = -5.3 to 4.5); the sensitivity of the triage was similar (difference -1.5%, 95% CI = -9.8 to 7.0) and the specificity was higher (difference 11.6%, 95% CI = 7.8 to 15.4); and both the sensitivity and specificity of the aided clinical judgement were higher (difference 8.0%, 95% CI = -6.9 to 23.0 and 5.8%, 95% CI = -1.6 to 13.2, respectively). ConclusionUsing the Marburg Heart Score for initial triage can improve the clinical diagnosis of CHD in general practice.Keywords chest pain; medical history taking; myocardial ischaemia; primary health care; sensitivity and specificity.

Der akute Thoraxschmerz – Schritt für Schritt

“…Der Marburger Herz-Score liefert einen Anhaltspunkt, ob eine koronare oder nicht koronare Ursache vorliegt. Treffen ≤ 2 der folgenden Faktoren zu, ist die Wahrscheinlich-keit für eine koronare Ursache der Beschwerden gering [9]: ▪ Alter und Geschlecht (Männer ≥ 55 Jahre, Frauen ≥ 65 Jahre) ▪ bekannte vaskuläre Erkrankung ▪ belastungsabhängige Beschwerden ▪ durch Palpation reproduzierbare Schmerzen ▪ der Patient vermutet eine kardiale Genese Besteht der Verdacht auf eine koronare Ursache der akuten thorakalen Beschwerden, wird die klinische Arbeitsdiagnose "akutes Koronarsyndrom" gestellt (▶ Abb. 1).…”

Acute coronary syndrome

“…Вместе с тем, согласно полу-ченным позднее данным, чувствительность определения низкой вероятности наличия ИБС у пациентов с жалобами на боль в груди составляет 82,9 % для врачебной оценки, что на 8 % ниже, чем оценка по шкале Marburg Heart Score при практически одинаковой специфичности [20]. Применение шкалы в до-полнение к врачебной оценке увеличивает и чувствительность, и специфичность опреде-ления низкой вероятности ИБС у пациента с болью в груди и позволяет точнее опреде-лить группу пациентов, обследование которых в первую очередь будет проводиться по схеме верификации экстракардиальных причин раз-вития симптоматики [20].…”

A Nationwide Flash-Mob Study for Suspected Acute Coronary Syndrome

“…T he Marburg Heart Score (MHS), a clinical decision rule based on 5 signs and symptoms (Table 1), has shown promising results in assisting family physicians (FPs) to identify patients with a low probability of acute coronary syndrome (ACS) as the underlying cause of chest pain in the primary care population. [1][2][3] In contrast to the History, Electrocardiogram, Age, Risk factors, and Troponin (HEART) score validated in emergency departments, additional diagnostic tests, such as electrocardiography (ECG) or cardiac troponin, are not included in the MHS. [4][5][6] Recently, a large meta-analysis of 3,099 primary care patients with chest pain identified 2 additional predictors of ACS, that is, the FP's suspicion of a serious diagnosis and a pain that feels like pressure.…”

“…7 However, the validity of the MHS and other possible predictors-including the FP's clinical assessment, which is infrequently assessed and compared with decision rules-in safely ruling out ACS in otherwise referred primary care patients is unclear. 3,8,9 Assessing the accuracy of clinical decision rules in family practice requires large prospective studies, which are time consuming and costly. Recently, an innovative research method, the flash-mob method, has been used in hospital-based studies, allowing for the investigation of 1 simple research question on a large scale and over a short time frame.…”