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Du Fay De Lavallaz, J; Badertscher, P B; Zimmermann, T Z; Nestelberger, T N; Walter, J W; Strebel, I S; Lohrmann, J S; Boeddinghaus, J B; Miro, O M; Than, M T; Martin-Sanchez, J M S; Cullen, L C; Kuehne, M K; Reichlin, T; Mueller, C M

P6570Performance of the early clinical judgement for the diagnosis of syncope on the emergency department

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  • Media type: E-Article
  • Title: P6570Performance of the early clinical judgement for the diagnosis of syncope on the emergency department
  • Contributor: Du Fay De Lavallaz, J; Badertscher, P B; Zimmermann, T Z; Nestelberger, T N; Walter, J W; Strebel, I S; Lohrmann, J S; Boeddinghaus, J B; Miro, O M; Than, M T; Martin-Sanchez, J M S; Cullen, L C; Kuehne, M K; Reichlin, T; Mueller, C M
  • Published in: European Heart Journal
  • Published: Oxford University Press (OUP), 2019
  • Language: English
  • DOI: 10.1093/eurheartj/ehz746.1159
  • ISSN: 0195-668X; 1522-9645
  • Keywords: Cardiology and Cardiovascular Medicine
  • Abstract: <jats:title>Abstract</jats:title> <jats:sec> <jats:title>Background</jats:title> <jats:p>Clinical judgement of the emergency department (ED) physician at time of discharge outperforms prognostic risk scores but the early clinical judgment (ECJ) regarding diagnosis has never been assessed.</jats:p> </jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>We evaluated the diagnostic accuracy of the ED physicians' ECJ 90 minutes after admission of patients &gt;40 years presenting with syncope to the ED in a prospective diagnostic multicenter study. Cardiac syncope, as adjudicated by two physicians based on information available including 1-year follow-up, was the diagnostic endpoint. Death and MACE were the prognostic endpoints. Lasso-regression was used to identify variables contributing most to the ECJ or to the diagnosis of cardiac syncope. Syncope-specific diagnostic and prognostic scores, high-sensitivity cardiac troponin I (hs-cTnI) and B-type natriuretic peptide (BNP) were used for comparison.</jats:p> </jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>Cardiac syncope was adjudicated in 252/1494 patients (15.2%). The diagnostic accuracy of the ECJ for cardiac syncope, as quantified by the Area Under the Curve (AUC), was 0.87 (95% CI 0.84–0.89) and was superior to the one of biomarkers and diagnostic score, constant between all centers, but poorly calibrated. 16 variables available very-early on the ED achieved a comparable performance (AUC 0.84 (95% CI 0.82–0.87), p=0.136).</jats:p> <jats:p>The extrapolated prognostic accuracy of the ECJ was moderate for MACE (AUC 0.73–0.8) but poor for death (0.58–0.63) over two years follow-up.</jats:p> <jats:p>Figure 1</jats:p> </jats:sec> <jats:sec> <jats:title>Conclusion</jats:title> <jats:p>The ECJ performs well for the diagnosis of cardiac syncope but a similar accuracy can be obtained using structured variables obtained very-early in the diagnostic process.</jats:p> </jats:sec> <jats:sec> <jats:title>Acknowledgement/Funding</jats:title> <jats:p>Swiss National Science Foundation, Swiss Heart Foundation, Cardiovascular Research Foundation, Basel (Switzerland), University Basel (Switzerland)</jats:p> </jats:sec>
  • Description: <jats:title>Abstract</jats:title>
    <jats:sec>
    <jats:title>Background</jats:title>
    <jats:p>Clinical judgement of the emergency department (ED) physician at time of discharge outperforms prognostic risk scores but the early clinical judgment (ECJ) regarding diagnosis has never been assessed.</jats:p>
    </jats:sec>
    <jats:sec>
    <jats:title>Methods</jats:title>
    <jats:p>We evaluated the diagnostic accuracy of the ED physicians' ECJ 90 minutes after admission of patients &gt;40 years presenting with syncope to the ED in a prospective diagnostic multicenter study. Cardiac syncope, as adjudicated by two physicians based on information available including 1-year follow-up, was the diagnostic endpoint. Death and MACE were the prognostic endpoints. Lasso-regression was used to identify variables contributing most to the ECJ or to the diagnosis of cardiac syncope. Syncope-specific diagnostic and prognostic scores, high-sensitivity cardiac troponin I (hs-cTnI) and B-type natriuretic peptide (BNP) were used for comparison.</jats:p>
    </jats:sec>
    <jats:sec>
    <jats:title>Results</jats:title>
    <jats:p>Cardiac syncope was adjudicated in 252/1494 patients (15.2%). The diagnostic accuracy of the ECJ for cardiac syncope, as quantified by the Area Under the Curve (AUC), was 0.87 (95% CI 0.84–0.89) and was superior to the one of biomarkers and diagnostic score, constant between all centers, but poorly calibrated. 16 variables available very-early on the ED achieved a comparable performance (AUC 0.84 (95% CI 0.82–0.87), p=0.136).</jats:p>
    <jats:p>The extrapolated prognostic accuracy of the ECJ was moderate for MACE (AUC 0.73–0.8) but poor for death (0.58–0.63) over two years follow-up.</jats:p>
    <jats:p>Figure 1</jats:p>
    </jats:sec>
    <jats:sec>
    <jats:title>Conclusion</jats:title>
    <jats:p>The ECJ performs well for the diagnosis of cardiac syncope but a similar accuracy can be obtained using structured variables obtained very-early in the diagnostic process.</jats:p>
    </jats:sec>
    <jats:sec>
    <jats:title>Acknowledgement/Funding</jats:title>
    <jats:p>Swiss National Science Foundation, Swiss Heart Foundation, Cardiovascular Research Foundation, Basel (Switzerland), University Basel (Switzerland)</jats:p>
    </jats:sec>
  • Footnote:
  • Access State: Open Access