Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2022 Oct 5;12(10):e064402.
doi: 10.1136/bmjopen-2022-064402.

Development and validation of a prediction rule for patients suspected of acute coronary syndrome in primary care: a cross-sectional study

Loes T C M Wouters  1 , Dorien L M Zwart  2 , Daphne C A Erkelens  2 , Elisabeth J M Adriaansen  2 , Hester M den Ruijter  3 , Esther De Groot  4 , Roger A M J Damoiseaux  2 , Arno W Hoes  2 , Maarten van Smeden  5 , Frans H Rutten  2
Affiliations

Development and validation of a prediction rule for patients suspected of acute coronary syndrome in primary care: a cross-sectional study

Loes T C M Wouters et al. BMJ Open. .

Abstract

Objective: To develop and validate a symptom-based prediction rule for early recognition of acute coronary syndrome (ACS) in patients with acute chest discomfort who call out-of-hours services for primary care (OHS-PC).

Design: Cross-sectional study. A diagnostic prediction rule was developed with multivariable regression analyses. All models were validated with internal-external cross validation within seven OHS-PC locations. Both age and sex were analysed as statistical interaction terms, applying for age non-linear effects.

Setting: Seven OHS-PC in the Netherlands.

Participants: 2192 patients who called OHS-PC for acute chest discomfort (pain, pressure, tightness or discomfort) between 2014 and 2017. Backed up recordings of telephone triage conversations were analysed.

Primary and secondary outcomes measures: Diagnosis of ACS retrieved from the patient's medical records in general practice, including hospital specialists discharge letters. Performance of the prediction rules was calculated with the c-statistic and the final model was chosen based on net benefit analyses.

Results: Among the 2192 patients who called the OHS-PC with acute chest discomfort, 8.3% females and 15.3% males had an ACS. The final diagnostic model included seven predictors (sex, age, acute onset of chest pain lasting less than 12 hours, a pressing/heavy character of the pain, radiation of the pain, sweating and calling at night). It had an adjusted c-statistic of 0.77 (95% CI 0.74 to 0.79) with good calibration.

Conclusion: The final prediction model for ACS has good discrimination and calibration and shows promise for replacing the existing telephone triage rules for patients with acute chest discomfort in general practice and OHS-PC.

Trial registration number: NTR7331.

Keywords: myocardial infarction; primary care; telemedicine.

PubMed Disclaimer

Conflict of interest statement

Competing interests: None declared.

Figures

Figure 1
Figure 1
Flowchart of study population. ACS, acute coronary syndrome; ICPC, International Code for Primary Care; OHS-PC, out-of-hours services for primary care.
Figure 2
Figure 2
Base model with age and sex for predicting diagnosis acute coronary syndrome. ACS, acute coronary syndrome.
Figure 3
Figure 3
Callibration of the final model with internal external validation.
Figure 4
Figure 4
Decision curve analyses comparing the full and final models versus the currently used model and versus treat all patients. NTS, Netherlands Triage Standard.
Figure 5
Figure 5
Runway plot of diagnostic accuracy measures of the final model.
See this image and copyright information in PMC

Similar articles

See all similar articles

Cited by

References

    1. Rui P, Kang K. National Hospital ambulatory medical care survey: 2017 emergency department summary tables. Available: cdc.gov
    1. Mol KA, Smoczynska A, Rahel BM, et al. . Non-cardiac chest pain: prognosis and secondary healthcare utilisation. Open Heart 2018;5:e000859. 10.1136/openhrt-2018-000859 - DOI - PMC - PubMed
    1. Collet J-P, Thiele H, Barbato E, et al. . 2020 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Rev Esp Cardiol 2021;74:544. 10.1016/j.rec.2021.05.002 - DOI - PubMed
    1. Burman RA, Zakariassen E, Hunskaar S. Management of chest pain: a prospective study from Norwegian out-of-hours primary care. BMC Fam Pract 2014;15:51. 10.1186/1471-2296-15-51 - DOI - PMC - PubMed
    1. Deakin CD, Sherwood DM, Smith A, et al. . Does telephone triage of emergency (999) calls using advanced medical priority dispatch (AMPDS) with department of health (DH) call prioritisation effectively identify patients with an acute coronary syndrome? an audit of 42,657 emergency calls to Hampshire ambulance service NHS trust. Emerg Med J 2006;23:232–5. 10.1136/emj.2004.022962 - DOI - PMC - PubMed

Publication types