Feature

Playing by the Rules: Using Decision Rules Wisely Part 2, Nontraumatic Conditions

Emergency Medicine. 2018 December;50(12):1-14

References

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30. Hess EP, Perry JJ, Calder LA, et al. Prospective validation of a modified Thrombolysis In Myocardial Infarction risk score in emergency department patients with chest pain and possible acute coronary syndrome. Acad Emerg Med. 2010;17(4):368-375.

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34. Carlton EW, Khattab A, Greaves K. Identifying patients suitable for discharge after a single-presentation high-sensitivity Troponin result: a comparison of five established risk scores and two high-sensitivity assays. Ann Emerg Med. 2015;66(6):635-645.

35. Poldervaart JM, Langedijk M, Backus BE, et al. Comparison of the GRACE, HEART and TIMI score to predict major adverse cardiac events in chest pain patients at the emergency department. Int J Cardiol. 2017;227:656-661.

36. Nieuwets A, Poldervaart JM, Reitsma JB, et al. Medical consumption compared for TIMI and HEART score in chest pain patients at the emergency department: a retrospective cost analysis. BMJ Open. 2016;6:e010694.

37. Wells PS, Ginsberg JS, Anderson DR, et al. Use of a clinical model for safe management of patients with suspected pulmonary embolism. Ann Intern Med. 1998;129:997-1005.

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39. Wells PS, Anderson DR, Rodger M, et al. Excluding pulmonary embolism at the bedside without diagnostic imaging: management of patients with suspected pulmonary embolism presenting to the emergency department by using a simple clinical model and D-dimer. Ann Intern Med. 2001;135:98-107.

40. Wolf SJ, McCubbin TR, Feldhaus KM, Faragher JP, Adcock DM. Prospective validation of Wells’ criteria in the evaluation of patients with suspected pulmonary embolism. Ann Emerg Med. 2004;44:503-510.

41. Chagnon I, Bounameaux H, Aujesky D, et al. Comparison of two clinical prediction rules and implicit assessment among patients with suspected pulmonary embolism. Am J Med. 2002;113:269-275.

42. Christopher Study Investigators. Effectiveness of managing suspected pulmonary embolism using an algorithm combining clinical probability, D-dimer testing, and computed tomography. JAMA. 2006;295:172-179.

43. Kline JA, Mitchell AM, Kabrhel C, Richman PB, Courtney DM. Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism. J Thromb Haemost. 2004;2:1247-1255.

44. Kline JA, Courtney DM, Kabrhel C, et al. Propsective multicenter evaluation of the pulmonary embolism rule-out criteria. J Thromb Haemost. 2008;6:772-780.

45. Penaloza A, Soulie C, Moumneh T, et al. Pulmonary embolism rule-out criteria (PERC) rule in European patients with low implicit clinical probability (PERCEPIC): a multicenter, prospective, observational study. Lancet Haematol. 2017;4:e615-e621.

46. Freund Y, Cachanado M, Aubry A, et al. Effect of the Pulmonary Embolism Rule-Out Criteria on subsequent thromboembolic events among low-risk emergency department patients. The PROPER randomized clinical trial. JAMA. 2018;319(6):559-566.

47. Hugli O, Righini M, Le Gal G, et al. The pulmonary embolism rule-out criteria (PERC) rule does not safely exclude pulmonary embolism. J Thromb Haemost. 2011;9:300-4.

48. Theunissen JMG, Scholing C, van Hasselt WE, van der Maten J, ter Avest E. A retrospective analysis of the combined use of PERC rule and Wells score to exclude pulmonary embolism in the Emergency Department. Emerg Med J. 2016;33:696-701.

49. Singh B, Parsaik AK, Aharwal D, Surana A, Mascarenhas SS, Chandra S. Diagnostic accuracy of Pulmonary Embolism Rule-Out Criteria: a systematic review and meta-analysis. Ann Emerg Med. 2012;59(6):517-520.

50. Shapiro NI, Wolfe RE, Moore RB, Smith E, Burdick E, Bates DW. Mortality in Emergency Department Sepsis (MEDS) score: a prospectively derived and validated clinical prediction rule. Crit Care Med. 2003;31(3):670-675.

51. Shapiro NI, Howell MD, Talmor D, Donnino M, Ngo L, Bates DW. Mortality in Emergency Department Sepsis (MEDS) score predicts 1-year mortality. Crit Care Med. 2007;35(1):192-198.

52. Sankoff JD, Goyal M, Gaieski DF, et al. Validation of the Mortality in Emergency Department Sepsis (MEDS) score in patients with the systemic inflammatory response syndrome (SIRS). Crit Care Med. 2008;36(2):421-26.

53. Jones AE, Saak K, Kline JA. Performance of the Mortality in Emergency Department Sepsis score for predicting hospital mortality among patients with severe sepsis and septic shock. Am J Emerg Med. 2008;26(6):689-692.

54. Carpenter CR., Keim SM, Upadhye S, Nguyen HB. Risk stratification of the potentially septic patient in the emergency department: the Mortality in the Emergency Department Sepsis (MEDS) score. J Emerg Med. 2009;37(3):319-327.

55. Hermans MAW, Leffers P, Jansen LM, Keulemans YC, Stassen PM. The value of the Mortality in Emergency Department Sepsis (MEDS) score, C reactive protein and lactate in predicting 28-day mortality of sepsis in a Dutch emergency department. Emerg Med J. 2012;29(4):295–300.

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Most recently, a stepped-wedge, cluster randomized trial across 9 hospitals published in 2017 investigated the utility of the HEART score. Despite enrolling only 3648 patients out of the statistically required sample size of 6600, they found that the HEART score was not inferior to usual care and there was no significant difference in median length of stay, but health care resources were typically lower in the HEART score group.²³

Comment: While derived in a less conventional manner, the HEART score has held up in several validation studies and appears poised to safely decrease health care costs and increase ED efficiency and throughput. As more US EDs look to adopt high sensitivity troponin biomarkers, prospective studies will be needed to determine the role of the HEART score in this setting.

Thrombolysis in Myocardial Infarction (TIMI) score

The Thrombolysis in Myocardial Infarction (TIMI) score was developed in 2000 as a tool to risk-stratify patients with a diagnosis of unstable angina (UA) and non–ST-elevation myocardial infarction (NSTEMI). The score was derived from 1 arm (2047 patients) of a study comparing heparin with enoxaparin for treatment of NSTEMI, and validated in the other 3 arms of the study (5124 patients). Multivariate logistic regression was used to develop 7 variables of equal weight:

Age greater than or equal to 65yo
Three or more cardiac risk factors
Known coronary artery disease (with stenosis greater than or equal to 50%)
Aspirin use in the past 7 days
Severe angina (2 or more episodes in the past 24 hours)
EKG ST changes greater than or equal to 0.5 mm
Positive serum cardiac biomarkers

The investigators found that with a higher score, there was progressive increase in adverse cardiac outcomes, with a c-statistic of 0.65.²⁴ This score was subsequently validated across several existing databases evaluating various therapeutic interventions for UA/NSTEMI and remained statistically significant, with increasing risk for MI and mortality with increasing score.^25,26

Given the success in predicting patient outcomes and identifying patients who could benefit from more aggressive care, the TIMI risk score was then applied to unselected ED chest pain patients. In a secondary analysis of a prospective observational cohort of 3929 patient visits, the TIMI score correlated to the risk for adverse outcomes, with a risk of 2.1% at score 0.²⁷