Walter Renier

Coronary heart disease in primary care: accuracy of medical history and physical findings in patients with chest pain – a study protocol for a systematic review with individual patient data

BackgroundChest pain is a common complaint in primary care, with coronary heart disease (CHD) being the most concerning of many potential causes. Systematic reviews on the sensitivity and specificity of symptoms and signs summarize the evidence about which of them are most useful in making a diagnosis. Previous meta-analyses are dominated by studies of patients referred to specialists. Moreover, as the analysis is typically based on study-level data, the statistical analyses in these reviews are limited while meta-analyses based on individual patient data can provide additional information. Our patient-level meta-analysis has three unique aims. First, we strive to determine the diagnostic accuracy of symptoms and signs for myocardial ischemia in primary care. Second, we investigate associations between study- or patient-level characteristics and measures of diagnostic accuracy. Third, we aim to validate existing clinical prediction rules for diagnosing myocardial ischemia in primary care. This article describes the methods of our study and six prospective studies of primary care patients with chest pain. Later articles will describe the main results.Methods/DesignWe will conduct a systematic review and IPD meta-analysis of studies evaluating the diagnostic accuracy of symptoms and signs for diagnosing coronary heart disease in primary care. We will perform bivariate analyses to determine the sensitivity, specificity and likelihood ratios of individual symptoms and signs and multivariate analyses to explore the diagnostic value of an optimal combination of all symptoms and signs based on all data of all studies. We will validate existing clinical prediction rules from each of the included studies by calculating measures of diagnostic accuracy separately by study.DiscussionOur study will face several methodological challenges. First, the number of studies will be limited. Second, the investigators of original studies defined some outcomes and predictors differently. Third, the studies did not collect the same standard clinical data set. Fourth, missing data, varying from partly missing to fully missing, will have to be dealt with.Despite these limitations, we aim to summarize the available evidence regarding the diagnostic accuracy of symptoms and signs for diagnosing CHD in patients presenting with chest pain in primary care.Review registrationCentre for Reviews and Dissemination (University of York): CRD42011001170

Signs and symptoms in adult patients with acute dyspnea: a systematic review and meta-analysis

Introduction Rapid and accurate diagnosis of patients with a new episode of acute dyspnea is a common challenge for Primary Care or Emergency Physicians. Objective To determine the diagnostic accuracy of signs and symptoms in adult patients with a new episode of acute dyspnea presenting to a GP or an Emergency Physician (EP). Patients and methods This was a diagnostic systematic review. Using MEDLINE, Cumulative Index to Nursing and Allied Health Literature, EMBASE, tracing references, and by contacting experts, studies were identified on the diagnostic accuracy of additional signs and symptoms in adult patients with acute or suddenly worsening dyspnea, presenting to a GP or an EP. Study quality was assessed using QUADAS and results were pooled using a random-effects model. Sensitivity, specificity, positive and negative likelihood ratio (NLR), and positive and negative predictive values for a diagnosis of heart failure (HF) were calculated for the combination of acute dyspnea and each additional sign or symptom in the selected studies. Results Eight of the 24 identified studies were carried out in the ED and provided us with all the required data, including 4737 patients. All publications reported HF; two studies additionally investigated pulmonary embolism, acute exacerbations of chronic obstructive pulmonary disease or asthma, acute pulmonary infectious diseases, or acute coronary syndrome. The prevalence of HF in patients with acute dyspnea ranged from 25 to 59%. Heterogeneity was present in all analyses. Comparing signs and symptoms, sensitivity was very poor for the presence of fever (0.05) and sputum production (0.06), and poor for fatigue (0.36–0.76), orthopnea (0.2–0.76), paroxysmal nocturnal dyspnea (0.23–0.70), elevated jugular venous pressure (0.19–0.70), rales (0.32–0.88), and peripheral edema (0.29–0.77). Specificity was poor for fatigue (0.28–0.69), moderate for the presence of fever (0.76–0.88), sputum production (0.73–0.89), orthopnea (0.49–0.92), paroxysmal nocturnal dyspnea (0.52–0.93), and rales (0.31–0.98), and good for elevated jugular venous pressure (0.75–0.97) and peripheral edema (0.67–0.89). For all other signs and symptoms, sensitivities varied between 0.20 and 0.43; specificities for symptoms varied widely between 0.37 and 0.91 and those of signs between 0.20 and 1.0. The pooled sensitivities, however, remained poor: below 0.55. Pooled specificity of most signs ranged between 0.69 and 0.88. The positive likelihood ratio was between 0.64 and 4.11 and the NLR was between 0.59 and 1.29 with one outlier: rales (pooled NLR=0.35). Conclusion This systematic review, which only included patients from ED settings, did not identify any single sign or symptom that had acceptable sensitivity to be useful in ruling out a diagnosis of HF, chronic obstructive pulmonary disease, asthma, or pulmonary embolism. Elevated jugular venous pressure (0.88, pooled odds ratio: 7), added third heart sound (0.97), and lung crepitations (0.77, pooled odds ratio: 11) are useful in ruling in HF.

The frequency and outcome of acute dyspnoea in primary care: An observational study

Abstract Background: Little is known about the occurrence of acute dyspnoea in primary care and its underlying causes. Objectives: What are the occurrence and most frequent causes of acute dyspnoea in primary care, predictors of referral, hospitalization, death and possible underlying causes? Methods: Twenty-five general practitioners (GPs) in Flanders (Belgium) recorded patient contacts for four periods of two weeks during one year. They recorded patients presenting with acute dyspnoea, location of contact (surgery versus home visit), new dyspnoea versus exacerbation, tentative diagnosis, referral to a specialist and hospital, and one month later final diagnosis, its justification, referral, hospitalization and death. Results: Twenty-two GPs recorded 14,620 patient contacts. Acute dyspnoea was encountered in 317 patient–doctor contacts (2.2%; 95%CI: 1.9–2.4), without significant association between the acute dyspnoea frequency, and age and gender. Immediate referral and hospitalization were most frequent in patients 61 to 90 years old. Forty-five patients (14.2%; 95%CI: 10.4–18.0) were referred to a specialist immediately and an additional 34 (10.7%; 95%CI: 7.3–14.1) by one month follow-up. Fourteen patients (4.4%) were hospitalized immediately, and 11 (3.5%) within one month. Six patients (1.9%), all 61 to 90 years old, died within one month. Conclusion: Dyspnoea occurs in about two per cent of consultations. Serious cases are rare and are much more likely in the older age group. Twenty-five per cent of the contacts concerning acute or worsening dyspnoea were referred to a specialist or hospitalized. In daily practice, the risk of immediate referral, hospitalization and death is higher in men and older patients, especially if the contact is at the patient’s home. Key Messages Acute dyspnoea was encountered in 2.2% of patient–doctor contacts. The risk of immediate referral, hospitalization and death was higher in men and patients 61 to 90 years old, especially if the contact was at the patient’s home. There is no association between the acute dyspnoea frequency and age and gender.

Kan een e-module de kennis van Basic Life Support verbeteren?

SamenvattingEen plotse hartstilstand is een van de belangrijkste doodsoorzaken in Europa. Jaarlijks worden in Europa 350 000 tot 700 000 personen hierdoor getroffen.1