Don’t discount clinical gestalt just yet

Whether to ‘rule out’ or ‘rule in’ AMI in the emergency department, we have many tools at our disposal. In brief, though not exhaustive, we have in recent years the following:

1. The HEART score

Backus E, et al. A prospective validation of the HEART score for chest pain patients at the emergency department. International Journal of Cardiology 2013, Oct;168(3):2153-8.

2. The 2 hour AMI rule out

Than M, et al. 2-Hour accelerated diagnostic protocol to assess patients with chest pain symptoms using contemporary troponins as the only biomarker: The ADAPT trial. J Am Coll Cardiol 2012, Jun 5;59(23):2091-8.

3. Even the 1 hour rule out AMI

Reichlin T. et al. One-Hour rule-out and rule-in of acute myocardial infarction using high-sensitivity cardiac troponin T. Arch Intern Med 2012, Aug 13:1-8.

Now, in the latest issue of EMJ, researchers asked if emergency physicians can possibly ‘rule in’ and ‘rule out’ AMI with clinical judgement i.e. clinical gestalt?

Body R, Cook G, Burrows G, Carley S, Lewis  S, Jarvis J, Haves B. Can emergency physicians ‘rule in’ and ‘rule out’ acute myocardial infarction with clinical judgement? Emergency Medicine Journal 2014, Nov 1;31(11):872-6.

This single centre observational study recruited 458 patients with suspected cardiac chest pain. ‘Gestalt’ or clinical judgement about the probability of an ACS was assessed using a five-point Likert scale as follows: ‘definitely not’, ‘probably not’, ‘not sure’, ‘probably’ and ‘definitely’.

So, clinical gestalt alone wouldn’t cut it, with a ROC of 0.76, but with ECG and a hs-cTnT, the sensitivity was 100% in cases in which ACS was determined as ‘definitely not’ and ‘probably not’. Specificity, as with other studies, was low (<50%).

Bottom line

Yep, you don’t really need a score per se. Good clinical judgement, good read of the ECG and with the help of troponin (high sensitive if you have it) will help you make a good clinical decision at the bedside in the emergency department.

Limitations and caveats

• Still a single centre, observational study. Not an RCT, and probably needs validation
• Good sample representation – sample has significant number of AMIs and MACE – 21.8%
• Well defined outcomes and good follow-up – e.g. AMI definitions and 30 day MACE
• Doctors in study of varying skill level (SHOs all to way to consultants)
• Still require the use of a custom-designed case report form when assessing patients – i.e. some kind of “score” already in my mind.
• Single troponin only used when >12 h had already elapsed since peak symptoms, as opposed to latest ACC/AHA guidelines