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

Erik P. Hess, Venkatesh Thiruganasambandamoorthy, George A. Wells, Patricia Erwin, Allan S Jaffe, Judd E. Hollander, Victor Manuel Montori, Ian G. Stiell

Research output: Contribution to journalArticle

53 Citations (Scopus)

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.

Original languageEnglish (US)
Pages (from-to)373-382
Number of pages10
JournalCanadian Journal of Emergency Medicine
Volume10
Issue number4
StatePublished - Jul 2008

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Decision Support Techniques
Acute Coronary Syndrome
Hospital Emergency Service
Coronary Angiography
MEDLINE
Physical Examination
Electrocardiography
Biomarkers
History
Databases
Sensitivity and Specificity
Research

Keywords

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

ASJC Scopus subject areas

  • Emergency Medicine

Cite this

Hess, E. P., Thiruganasambandamoorthy, V., Wells, G. A., Erwin, P., Jaffe, A. S., Hollander, J. E., ... Stiell, I. G. (2008). Diagnostic accuracy of clinical prediction rules to exclude acute coronary syndrome in the emergency department setting: A systematic review. Canadian Journal of Emergency Medicine, 10(4), 373-382.

Diagnostic accuracy of clinical prediction rules to exclude acute coronary syndrome in the emergency department setting : A systematic review. / Hess, Erik P.; Thiruganasambandamoorthy, Venkatesh; Wells, George A.; Erwin, Patricia; Jaffe, Allan S; Hollander, Judd E.; Montori, Victor Manuel; Stiell, Ian G.

In: Canadian Journal of Emergency Medicine, Vol. 10, No. 4, 07.2008, p. 373-382.

Research output: Contribution to journalArticle

Hess, Erik P. ; Thiruganasambandamoorthy, Venkatesh ; Wells, George A. ; Erwin, Patricia ; Jaffe, Allan S ; Hollander, Judd E. ; Montori, Victor Manuel ; Stiell, Ian G. / Diagnostic accuracy of clinical prediction rules to exclude acute coronary syndrome in the emergency department setting : A systematic review. In: Canadian Journal of Emergency Medicine. 2008 ; Vol. 10, No. 4. pp. 373-382.
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