Diagnostic accuracy of clinical prediction rules to exclude acute coronary syndrome in the emergency department setting: a systematic review

Abstract

Objective: We sought to determine the diagnostic accuracy of clinical prediction rules to exclude acute coronary syndrome (ACS) in the emergency department (ED) setting. Methods: We searched MEDLINE, EMBASE, Web of Science and the Cochrane Database of Systematic Reviews. We contacted content experts to identify additional articles for review. Reference lists of included studies were hand searched. We selected articles for review based on the following criteria: 1) enrolled consecutive ED patients; 2) incorporated variables from the history or physical examination, electrocardiogram and cardiac biomarkers; 3) did not incorporate cardiac stress testing or coronary angiography into prediction rule; 4) based on original research; 5) prospectively derived or validated; 6) did not require use of a computer; and 7) reported sufficient data to construct a 2 ∞ 2 contingency table. We assessed study quality and extracted data independently and in duplicate using a standardized data extraction form. Results: Eight studies met inclusion criteria, encompassing 7937 patients. None of the studies verified the prediction rule with a reference standard on all or a random sample of patients. Six studies did not report blinding prediction rule assessors to reference standard results, and vice versa. Three prediction rules were prospectively validated. Sensitivities and specificities ranged from 94% to 100% and 13% to 57%, and positive and negative likelihood ratios from 1.1 to 2.2 and 0.01 to 0.17, respectively. Conclusion: Current prediction rules for ACS have substantial methodological limitations and have not been successfully implemented in the clinical setting. Future methodologically sound studies are needed to guide clinical practice. RÉSUMÉObjectif : Nous avons cherché à déterminer l'exactitude diagnostique des règles de prévision clinique visant à exclure le syndrome coronarien aigu (SCA) dans les salles d'urgence.

Part 10: Acute Coronary Syndromes

“…No simple clinical decision rule is adequate and appropriate to identify ED chest discomfort patients with suspected ACS who can be safely discharged from the ED. 160 The use of inpatient-derived risk scoring systems are useful for prognosis (Class I, LOE A) but are not recommended to identify patients who may be safely discharged from the ED (Class III, LOE C).…”

Accuracy of enzyme-linked immunospot assay for diagnosis of pleural tuberculosis: a meta-analysis

“…Since the DOR value and SROC curve analysis are difficult to translate directly into clinical terms (Deeks, 2001), diagnostic accuracy is often assessed using PLR and NLR (Deeks, 2001;Hess et al, 2008). The pooled PLR value of 8.21 suggests that patients with tuberculous pleurisy are approximately 8-fold more likely to give a positive ELISPOT test result than patients without it.…”

Development and validation of a prediction rule for early discharge of low-risk emergency department patients with potential ischemic chest pain

“…21 Many rules are hampered by selection bias, a suboptimal methodological design, or low sensitivity. 28,29 There has been no widely used clinical prediction rule for safe early discharge of such patients, and the few rules that have been validated permit risk stratification of selected patients but do not allow for minimal investigations or early discharge.…”