Clinical Gestalt and TIMI Risk Score in Predicting Major Cardiac Event in Patients with Chest Pain at Emergency Department

Yıl 2024, , 207 - 215, 30.09.2024

Damla Anbarlı Metin , Sedat Yanturalı , Zeyneo Ertürk , Emre Şancı

https://doi.org/10.46871/eams.1518638

Öz

Background
Chest pain is one of the leading complaints causing Emergency Department (ED) admissions. Approximately 25% of all ED visits are due to acute coronary syndrome (ACS). The TIMI risk score is a commonly and easily used bedside risk scoring method.

Objective
In this prospective observational study, the TIMI risk score and clinical gestalt were compared in terms of detecting a major adverse cardiac event (MACE) in patients presenting with chest pain at ED.

Methods
A total of 351 patients were evaluated by experienced clinicians in respect of the TIMI risk score (1-7 points) and clinical gestalt (in terms of low-, medium- and high-risk major adverse cardiac event). The primary outcome was a major adverse cardiac event within 14 days of presentation at ED.

Results
A major adverse cardiac event occurred within 14 days in 87 (24.7%) of 351 patients. The sensitivity of clinical gestalt was 93.10% (85.59%-97.43%), and the specificity of the TIMI risk score was 75.89% (71.33%-81.84%). The TIMI risk score and clinical gestalt were found to have similar results in detecting a major cardiac event (AUC: 0.75; AUC: 0.72).

Conclusions
The results of the present study showed that TIMI scoring and clinical gestalt detect any major adverse cardiac event at similar rates in patients presenting with chest pain at ED.

Anahtar Kelimeler

TIMI score, clinical gestalt, chest pain, major adverse cardiac event

Acil Serviste Göğüs Ağrısı ile Başvuran Hastalarda Klinik Gestalt ve TIMI Risk Skorunun Major Kardiyak Olayı Öngörmedeki yeri

Öz

Giriş
Göğüs ağrısı, Acil Servis (AS) başvurularına neden olan önemli şikayetlerden biridir. Göğüs ağrısı nedeniyle olan AS başvurularının yaklaşık %25'i akut koroner sendrom (AKS) nedeniyle gerçekleşmektedir. TIMI risk skoru, yaygın ve kolayca kullanılan bir yatak başı risk skorlama yöntemidir.
Bu prospektif gözlemsel çalışmada, TIMI risk skoru ve klinik gestaltın , Acil Servis'e göğüs ağrısı ile başvuran hastalarda major kardiyak olay (MACE) tespitinde karşılaştırıldı.

Materyal- Metot
Toplamda 351 hasta, deneyimli klinisyenler tarafından TIMI risk skoru (1-7 puan) ve klinik değerlendirme (major kardiyak olay açısından düşük, orta ve yüksek riskli ) açısından değerlendirildi. Birincil sonuç, AS başvurusundan sonraki 14 gün içinde major kardiyak olaydı.

Bulgular
351 hastanın 87'sinde (%24,7) 14 gün içinde major kardiyak olay meydana geldi. Klinik gestaltın duyarlılığı %93,10 (85,59%-97,43%) ve TIMI risk skorunun özgüllüğü %75,89 (71,33%-81,84%) olarak bulundu. TIMI risk skoru ve klinik gestaltın, major kardiyak olayı tespit etmede benzer sonuçlar verdiği tespit edildi (AUC: 0,75; AUC: 0,72).
Sonuç
Bu çalışmanın sonuçları, Acil Servis'e göğüs ağrısı ile başvuran hastalarda TIMI puanlaması ve klinik değerlendirmenin herhangi bir major kardiyak olayı tespit etmede benzer oranlarda olduğunu göstermiştir.

Anahtar Kelimeler

klinik gestalt, TIMI skoru, major kardiyak olay, göğüs ağrısı

Kaynakça

• 1. V Anniek, WAlbert, BRob, et al. HEART score and clinical gestalt have similar diagnostic accuracy for diagnosing ACS in an unselected population of patients with chest pain presenting in the ED, Emerg Med J 2015;32:595–600. doi:10.1136/emermed-2014-203798.
• 2. Chase M, Robey JL, Zogby KE, et al. Prospective validation of the Thrombolysis in Myocardial Infarction Risk Score in the emergency department chest pain population. Ann Emerg Med 2006;48:252–9. https://doi.org/10.1016/j.annemergmed.2006.01.032
• 3. Writing Committee Members, Gulati M, Levy PD, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Journal of cardiovascular computed tomography, 16(1):54–122. https://doi.org/10.1016/j.jcct.2021.11.009.
• 4. Cook C, Is Clinical Gestalt Good Enough? J Man Manip Ther, 2009;17(1): 6-7.
• 5. Kabrhel C, Camargo CA, Goldhaber SZ. Clinical gestalt and the diagnosis of pulmonary embolism: Does experience matter? Chest 2008;127:1627–1630. https://doi.org/10.1378/chest.127.5.1627.
• 6. Koontz NA, Gunderman RB. Gestalt theory: Implications and radiology education. AJR 2008;190:1156–1160. https://doi.org/10.2214/AJR.07.3268.
• 7. Croskerry P, Norman G. Overconfidence in clinical decision making. Am J Med 2008;121:24–29.
• 8. Wong CP, Lui CT, Sung JG, et al. Prognostıcatıng Clınıcal Predıctıon Scores Wıthout Clınıcal Gestalt For Patıents Wıth Chest Paın In The Emergency Department, The Journal od Emergency Medicane 2017. https://doi.org/10.1016/j.jemermed.2017.10.006.
• 9. Body R, Cook G, Burrows G, et al. Can emergency phsicians ‘rule in’ and ‘rule out’ acute myocardial infarction with clinical judgement? Emerg Med J 2014;31:872-876.
• 10. Mokhtari A, Dryver E, Söderholm E ,et al. Diagnostic values of chest pain history, ECG, troponin and clinical gestalt in patients with chest pain and poteintial acute coronary syndrome assessed in the emergency department, Springerplus. 2015 May 7;4:219. doi: 10.1186/s40064-015-0992-9. eCollection 2015.
• 11. Soto-Mota A, Marfil-Garza BA, Castiello-de Obeso S, et al . Prospective predictive performance comparison between clinical gestalt and validated COVID-19 mortality scores. J Investig Med. 2022 Feb;70(2):415-420. doi: 10.1136/jim-2021-002037. Epub 2021 Oct 7. PMID: 34620707.
• 12. Quezada CA, Zamarro C, Gómez V,et al. Clinical gestalt versus prognostic scores for prognostication of patients with acute symptomatic pulmonary embolism. Med Clin (Barc). 2018 Aug 22;151(4):136-140. English, Spanish. https://doi.org/10.1016/j.medcle.2017.11.051. Epub 2017 Dec 21. PMID: 29276010.