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Both heart score, physician assessment fail to ‘safely’ rule out acute coronary syndrome
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Used independently, the Marburg Heart Score and a family practitioner’s assessment could not “safely” rule out acute coronary syndrome among patients with chest pain in The Netherlands, according to findings from a flash-mob study recently published in Annals of Family Medicine. In combination, they showed utility, but may not be practical for clinical use.
Angel M.R. Schols , MD, PhD, of the department of family medicine at Maastricht University in The Netherlands and colleagues asked family practitioners to assess the probability of acute coronary syndrome on a scale of one to 10 among 243 patients referred to secondary care for the condition. They evaluated the Marburg Test Score — which includes factors such as sex, age, known heart disease, patient’s thoughts on where pain is located, and pain not made worse with exercise or replicated by palpation — and family practitioner assessment — whether the attending family practitioner immediately suspected a serious diagnosis and his or her assessment of the likelihood of acute coronary syndrome, whether the patient indicated that the pain felt like pressure, how long the symptoms lasted and signs of ischemia on ECG if one was performed.
Schols and colleagues found that only 45 patients received a diagnosis of acute coronary syndrome. The sensitivity of the Marburg Heart Score (maximum score = 2) was 75%, specificity was 44%, positive predictive value was 24.3% and negative predictive value was 88%. For the family practitioner’s assessment (maximum score = 5), sensitivity was 86.7%, specificity was 41.4%, positive predictive value was 25.2% and negative predictive value was 93.2%.
“The Marburg Health Score and family practitioner assessments individually showed insufficient diagnostic accuracy to safely rule out acute coronary syndrome in referred patients. When combined, however, they safely reduced the number of referrals by 19% by applying the Marburg Heart Score only for referred patients considered to be at low risk of having an acute coronary syndrome by the family practitioner’s assessment. Yet, such a strategy meets practical limitations,” Schols and colleagues wrote.
“Family practitioners would have to apply this strategy after they made the decision to refer, meaning family practitioners should incidentally correct their decision to refer. Therefore, the suggested strategy should be validated in a sufficient large cohort including both referred and nonreferred patients with suspected acute coronary syndrome,” they added.
Researchers also discussed the rationale for utilizing a flash-mob approach for their study.
“Typical prospective research studies can large amounts of time and money,” Schols and colleagues wrote.
“Recently, an innovative research method, the flash-mob method, has been used in hospital-based studies, allowing for the investigation of one simple research question on a large scale and over a short time frame. Flash-mob research is based on the concept of flash mobs, ‘a large public gathering at which people perform an unusual or seemingly random act and then disperse, typically organized by means of the Internet or social media,’” they added.
Schols and colleagues cautioned that though they believe flash-mob research in family medicine is “feasible and that it may be considered for use as a new research method,” the technique is not applicable to all situations. – by Janel Miller
Disclosures : The authors report no relevant financial disclosures.
Perspective
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John Cole, MD, MS
As an epidemiologically trained stroke neurologist I am always keen to learn of new methodologies focusing on cardiovascular risk and prevention. In the recent study by Schols et al, a flash-mob approach was used for the first time as such a research methodology. While most individuals, including myself, typically think of a flash-mob as a group of individuals showing up at a pre-determined destination and time to perform some sort of stunt, that is not what ‘flash-mob’ refers to here. Rather, the investigators organized a large group of health care providers that were geographically distributed throughout The Netherlands and had them perform the same set of evaluations on different patients presenting with a similar symptom, namely chest pain potentially of cardiac origin.
The primary objective of the study was to evaluate the Marburg Heart Score as a clinical decision rule or to develop an adapted Marburg Heart Score/family physician clinical decision rule, allowing family physicians to safely rule out acute coronary syndrome in patients suspected to have the condition.The study’s secondary objective was to evaluate the feasibility of using the novel flash-mob methodology as a data collection instrument.
Ultimately, researchers concluded that in patients referred for emergency care, acute coronary syndrome could not be safely ruled out using the Marburg Heart Score or the family physician’s clinical assessment variables. In view of these findings, practicing physicians should not alter their current clinical practices. Despite the negative acute coronary syndrome results, the investigators did demonstrate that by utilizing the novel flash-mob methodology they could effectively investigate a clinically relevant set of research questions in family medicine on a large-scale over a short period of time. While their acute coronary syndrome related findings will require replication, it seems likely that flash-mob methodologies could similarly be employed in the United States to answer these and other research questions. Given the paucity of publications using this methodology, the effectiveness of flash-mob research remains to be determined. In conclusion, these results provide a strong motivation going forward to utilize this methodology to investigate relatively simple clinical research questions in an inexpensive, quick and reliable manner.
University of Maryland Medical System
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