Derivation of a clinical decision rule for chest radiography in emergency department patients with chest pain and possible acute coronary syndrome

Erik P. Hess, Jeffrey J. Perry, Pam Ladouceur, George A. Wells, Ian G. Stiell

Research output: Contribution to journalArticle

7 Citations (Scopus)

Abstract

Objective: We derived a clinical decision rule to determine which emergency department (ED) patients with chest pain and possible acute coronary syndrome (ACS) require chest radiography. Methods: We prospectively enrolled patients over 24 years of age with a primary complaint of chest pain and possible ACS over a 6-month period. Emergency physicians completed standardized clinical assessments and ordered chest radiographs as appropriate. Two blinded investigators independently classified chest radiographs as "normal," "abnormal not requiring intervention" and "abnormal requiring intervention," based on review of the radiology report and the medical record. The primary outcome was abnormality of chest radiographs requiring acute intervention. Analyses included interrater reliability assessment (with κ statistics), univariate analyses and recursive partitioning. Results: We enrolled 529 patients during the study period between Jul. 1, 2007, and Dec. 31, 2007. Patients had a mean age of 59.9 years, 60.3% were male, 4.0% had a history of congestive heart failure and 21.9% had a history of acute myocardial infarction. Only 2.1% (95% confidence interval [CI] 1.1%-3.8%) of patients had radiographic abnormality of the chest requiring acute intervention. The κ statistic for chest radiograph classification was 0.81 (95% CI 0.66-0.95). We derived the following rule: patients can forgo chest radiography if they have no history of congestive heart failure, no history of smoking and no abnormalities on lung auscultation. The rule was 100% sensitive (95% CI 32.0%-40.4%) and 36.1% specific (95% CI 32.0%-40.4%). Conclusion: This rule has potential to reduce health care costs and enhance ED patient flow. It requires validation in an independent patient population before introduction into clinical practice.

Original languageEnglish (US)
Pages (from-to)128-134
Number of pages7
JournalCanadian Journal of Emergency Medicine
Volume12
Issue number2
StatePublished - Mar 2010

Fingerprint

Acute Coronary Syndrome
Chest Pain
Radiography
Hospital Emergency Service
Thorax
Confidence Intervals
Heart Failure
Auscultation
Radiology
Health Care Costs
Medical Records
Emergencies
Smoking
Myocardial Infarction
Research Personnel
Physicians
Lung
Population

Keywords

  • Acute coronary syndrome
  • Diagnosis
  • Emergency medical services
  • Myocardial infarction
  • Radiography
  • Unstable angina

ASJC Scopus subject areas

  • Emergency Medicine

Cite this

Derivation of a clinical decision rule for chest radiography in emergency department patients with chest pain and possible acute coronary syndrome. / Hess, Erik P.; Perry, Jeffrey J.; Ladouceur, Pam; Wells, George A.; Stiell, Ian G.

In: Canadian Journal of Emergency Medicine, Vol. 12, No. 2, 03.2010, p. 128-134.

Research output: Contribution to journalArticle

Hess, Erik P. ; Perry, Jeffrey J. ; Ladouceur, Pam ; Wells, George A. ; Stiell, Ian G. / Derivation of a clinical decision rule for chest radiography in emergency department patients with chest pain and possible acute coronary syndrome. In: Canadian Journal of Emergency Medicine. 2010 ; Vol. 12, No. 2. pp. 128-134.
@article{9e3d8134cf9e47c09c6200c07cd841a3,
title = "Derivation of a clinical decision rule for chest radiography in emergency department patients with chest pain and possible acute coronary syndrome",
abstract = "Objective: We derived a clinical decision rule to determine which emergency department (ED) patients with chest pain and possible acute coronary syndrome (ACS) require chest radiography. Methods: We prospectively enrolled patients over 24 years of age with a primary complaint of chest pain and possible ACS over a 6-month period. Emergency physicians completed standardized clinical assessments and ordered chest radiographs as appropriate. Two blinded investigators independently classified chest radiographs as {"}normal,{"} {"}abnormal not requiring intervention{"} and {"}abnormal requiring intervention,{"} based on review of the radiology report and the medical record. The primary outcome was abnormality of chest radiographs requiring acute intervention. Analyses included interrater reliability assessment (with κ statistics), univariate analyses and recursive partitioning. Results: We enrolled 529 patients during the study period between Jul. 1, 2007, and Dec. 31, 2007. Patients had a mean age of 59.9 years, 60.3{\%} were male, 4.0{\%} had a history of congestive heart failure and 21.9{\%} had a history of acute myocardial infarction. Only 2.1{\%} (95{\%} confidence interval [CI] 1.1{\%}-3.8{\%}) of patients had radiographic abnormality of the chest requiring acute intervention. The κ statistic for chest radiograph classification was 0.81 (95{\%} CI 0.66-0.95). We derived the following rule: patients can forgo chest radiography if they have no history of congestive heart failure, no history of smoking and no abnormalities on lung auscultation. The rule was 100{\%} sensitive (95{\%} CI 32.0{\%}-40.4{\%}) and 36.1{\%} specific (95{\%} CI 32.0{\%}-40.4{\%}). Conclusion: This rule has potential to reduce health care costs and enhance ED patient flow. It requires validation in an independent patient population before introduction into clinical practice.",
keywords = "Acute coronary syndrome, Diagnosis, Emergency medical services, Myocardial infarction, Radiography, Unstable angina",
author = "Hess, {Erik P.} and Perry, {Jeffrey J.} and Pam Ladouceur and Wells, {George A.} and Stiell, {Ian G.}",
year = "2010",
month = "3",
language = "English (US)",
volume = "12",
pages = "128--134",
journal = "Canadian Journal of Emergency Medicine",
issn = "1481-8035",
publisher = "BC Decker Inc.",
number = "2",

}

TY - JOUR

T1 - Derivation of a clinical decision rule for chest radiography in emergency department patients with chest pain and possible acute coronary syndrome

AU - Hess, Erik P.

AU - Perry, Jeffrey J.

AU - Ladouceur, Pam

AU - Wells, George A.

AU - Stiell, Ian G.

PY - 2010/3

Y1 - 2010/3

N2 - Objective: We derived a clinical decision rule to determine which emergency department (ED) patients with chest pain and possible acute coronary syndrome (ACS) require chest radiography. Methods: We prospectively enrolled patients over 24 years of age with a primary complaint of chest pain and possible ACS over a 6-month period. Emergency physicians completed standardized clinical assessments and ordered chest radiographs as appropriate. Two blinded investigators independently classified chest radiographs as "normal," "abnormal not requiring intervention" and "abnormal requiring intervention," based on review of the radiology report and the medical record. The primary outcome was abnormality of chest radiographs requiring acute intervention. Analyses included interrater reliability assessment (with κ statistics), univariate analyses and recursive partitioning. Results: We enrolled 529 patients during the study period between Jul. 1, 2007, and Dec. 31, 2007. Patients had a mean age of 59.9 years, 60.3% were male, 4.0% had a history of congestive heart failure and 21.9% had a history of acute myocardial infarction. Only 2.1% (95% confidence interval [CI] 1.1%-3.8%) of patients had radiographic abnormality of the chest requiring acute intervention. The κ statistic for chest radiograph classification was 0.81 (95% CI 0.66-0.95). We derived the following rule: patients can forgo chest radiography if they have no history of congestive heart failure, no history of smoking and no abnormalities on lung auscultation. The rule was 100% sensitive (95% CI 32.0%-40.4%) and 36.1% specific (95% CI 32.0%-40.4%). Conclusion: This rule has potential to reduce health care costs and enhance ED patient flow. It requires validation in an independent patient population before introduction into clinical practice.

AB - Objective: We derived a clinical decision rule to determine which emergency department (ED) patients with chest pain and possible acute coronary syndrome (ACS) require chest radiography. Methods: We prospectively enrolled patients over 24 years of age with a primary complaint of chest pain and possible ACS over a 6-month period. Emergency physicians completed standardized clinical assessments and ordered chest radiographs as appropriate. Two blinded investigators independently classified chest radiographs as "normal," "abnormal not requiring intervention" and "abnormal requiring intervention," based on review of the radiology report and the medical record. The primary outcome was abnormality of chest radiographs requiring acute intervention. Analyses included interrater reliability assessment (with κ statistics), univariate analyses and recursive partitioning. Results: We enrolled 529 patients during the study period between Jul. 1, 2007, and Dec. 31, 2007. Patients had a mean age of 59.9 years, 60.3% were male, 4.0% had a history of congestive heart failure and 21.9% had a history of acute myocardial infarction. Only 2.1% (95% confidence interval [CI] 1.1%-3.8%) of patients had radiographic abnormality of the chest requiring acute intervention. The κ statistic for chest radiograph classification was 0.81 (95% CI 0.66-0.95). We derived the following rule: patients can forgo chest radiography if they have no history of congestive heart failure, no history of smoking and no abnormalities on lung auscultation. The rule was 100% sensitive (95% CI 32.0%-40.4%) and 36.1% specific (95% CI 32.0%-40.4%). Conclusion: This rule has potential to reduce health care costs and enhance ED patient flow. It requires validation in an independent patient population before introduction into clinical practice.

KW - Acute coronary syndrome

KW - Diagnosis

KW - Emergency medical services

KW - Myocardial infarction

KW - Radiography

KW - Unstable angina

UR - http://www.scopus.com/inward/record.url?scp=77957738340&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=77957738340&partnerID=8YFLogxK

M3 - Article

VL - 12

SP - 128

EP - 134

JO - Canadian Journal of Emergency Medicine

JF - Canadian Journal of Emergency Medicine

SN - 1481-8035

IS - 2

ER -