Key result
Emergency physician gestalt had fair diagnostic accuracy for acute coronary syndromes (C-statistic 0.75; 95% CI 0.72-0.79) and is not sufficiently accurate to rule in or rule out the diagnosis.
Why the study?
Early evidence suggested clinician gestalt alone might differentiate ED patients with chest pain needing admission from those safely discharged, but external validation of whether gestalt can rule in or rule out ACS was needed.
Does emergency physician gestalt accurately rule in or rule out acute coronary syndrome in emergency department patients with suspected ACS?
Cohort (n=1,391)
Yes
Does emergency physician gestalt accurately rule in or rule out acute coronary syndrome in emergency department patients with suspected ACS?
Emergency physician clinical gestalt alone is not sufficiently accurate or safe to be used as a decision-making strategy to rule in or rule out acute coronary syndrome.
Answers are grounded in this paper and cite their sources.
Gestalt alone should not guide ACS decisions in the ED; leaves open whether integrated tools improve accuracy beyond limited subsets.
BACKGROUND: Chest pain is a common problem presenting to the emergency department (ED). Many decision aids and accelerated diagnostic protocols have been developed to help clinicians differentiate those needing admission from those who can be safely discharged. Some early evidence has suggested that clinician judgment or gestalt alone could be sufficient. OBJECTIVES: Our aim was to externally validate whether emergency physician's gestalt could "rule in" or "rule out" acute coronary syndromes (ACS). METHODS: We performed a multicenter prospective diagnostic accuracy study including consenting patients presenting to the ED in whom the physician suspected ACS. At the time of arrival, clinicians recorded their perceived probability of ACS using a 5-point Likert scale. The primary outcome was a diagnosis of ACS, defined as acute myocardial infarction or major adverse cardiac events within 30 days. RESULTS: A total of 1,391 patients were included; 240 (17.3%) had ACS. Overall, gestalt had fair diagnostic accuracy with a C-statistic of 0.75 (95% confidence interval = 0.72 to 0.79). If ACS was "ruled out" in the 60 (4.3%) patients where clinicians perceived that the diagnosis was "definitely not" ACS, a sensitivity of 98.0% and negative predictive value of 95.0% could have been achieved. If ACS was only ruled out in patients who also had no electrocardiographic (ECG) ischemia and a normal initial cardiac troponin (cTn) concentration, 100.0% sensitivity and NPV could be achieved. However, this strategy only applied to 4.1% of patients. If patients with "probably not" ACS who had normal ECG and cTn were also ruled out (n = 418, 30.8%), sensitivity fell to 86.2% with 99.2% NPV. Using gestalt "definitely" ACS to rule in ACS gave a specificity of 98.5% and positive predictive value of 71.2%. CONCLUSION: Clinician gestalt is not sufficiently accurate or safe to either rule in or rule out ACS as a decision-making strategy. This study will enable emergency physicians to understand the limitations of our clinical judgment.
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Oliver et al. (2019) conducted a cohort in Suspected acute coronary syndromes (ACS) (n=1,391). Emergency physician gestalt was evaluated on Diagnosis of ACS, defined as acute myocardial infarction or major adverse cardiac events within 30 days (C-statistic 0.75, 95% CI 0.72 to 0.79). Emergency physician gestalt had fair diagnostic accuracy for acute coronary syndromes (C-statistic 0.75; 95% CI 0.72-0.79) and is not sufficiently accurate to rule in or rule out the diagnosis.
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