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Can Gestalt Rule In or Rule Out ACS?

September 2, 2019

Written by Clay Smith

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Physician gestalt of “definitely not” ACS + ECG + troponin had 100% sensitivity and 100% NPV for acute MI on presentation or MACE at 30-days.

Why does this matter?
We use decision aids, like HEART, to help us determine which chest pain patients are very low risk. But is physician gestalt just as good?

Not too shabby…
This was a pre-planned secondary analysis of BEST. Physicians, with unknown level of experience, evaluated 1,613 patients and used a 5-point Likert scale to assess clinical gestalt based on history, risk factors, +/- initial ECG, and +/- initial troponin. The primary outcome was MI at presentation or MACE at 30-days. In total, 240 patients (17.3%) met the primary outcome. Physicians were not blinded to the ECG or troponin results; so, be skeptical when the study measures gestalt alone without ECG or troponin. When the clinician believed the diagnosis was “definitely not” ACS, results were:

  • Sensitivity/NPV for gestalt alone: 98.8%/95%

  • Sensitivity/NPV for gestalt + ECG: 98.3%/94.9%

  • Sensitivity/NPV for gestalt + ECG + first troponin (<99th percentile): 100%/100%

If gestalt was “definitely not” or “probably not” + ECG + troponin, sensitivity was 86.2% and NPV 99.2%. Overall, diagnostic accuracy of gestalt was 0.75 (area under the curve). For ruling in ACS, when physicians said it was “definitely” ACS, specificity was 98.5%, PPV 71.2%.

The authors concluded, “Clinician gestalt is not sufficiently accurate or safe to either ‘rule in’ or ‘rule out’ ACS as a decision-making strategy.” However, it was impossible to isolate gestalt alone in this study. I think it is promising that gestalt “definitely not” + ECG + single troponin had 100% sensitivity/100% NPV. But this strategy would have only ruled out 4% of patients.

Can emergency physician gestalt “rule in” or “rule out” acute coronary syndrome: validation in a multi-center prospective diagnostic cohort study. Acad Emerg Med. 2019 Jul 24. doi: 10.1111/acem.13836. [Epub ahead of print]

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Reviewed by Thomas Davis

What are your thoughts?