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Validation of a Decision Rule and Derivation of a Modified Rule to Obtain Chest Radiograph in Patients with Nontraumatic Chest Pain in the Emergency Department

DOI: 10.1155/2014/241935

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Abstract:

Objectives. We sought to validate and refine a decision rule for chest X-ray (CXR) utilization in nontraumatic chest pain (CP) patients presenting to the emergency department (ED). Methods. Retrospective review of ED patients presenting with CP who had CXR performed during three nonconsecutive months was performed. The presence of 18 variables derived from history and exam was ascertained. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the original rule were calculated. Refinement using additional variables was performed. Results. 967 patient charts were reviewed. 89.9% of CXR were normal, 5.2% had insignificant findings, and 5.1% had significant findings. Application of the criteria had a sensitivity/specificity of 74%/59% and a PPV/ NPV of 9%/98%. Rule modification to obtain CXR for age ≥ 65 years, history of congestive heart failure and alcohol abuse, and exam findings of decreased breath sounds, fever, and tachypnea maintained sensitivity while improving specificity to 69%. Conclusions. Most CP patients have normal CXRs. Narrowing a decision rule to obtain CXR in patients with age ≥ 65 years, history of congestive heart failure and alcohol abuse, and exam findings of decreased breath sounds, fever, and tachypnea maintain sensitivity while improving specificity and NPV. 1. Introduction Chest pain remains one of the most common patient presentations to the emergency department (ED). In fact, a study from 2005 demonstrated more than 6 million annual ED visits with a chief complaint of chest pain [1]. The differential diagnosis of chest pain is extensive, and a handful of immediately life-threatening causes must be considered and excluded when evaluating a patient presenting with chest pain. While the utility of EKG and troponin testing in the evaluation of patients with potential acute coronary syndrome has been demonstrated [2, 3], there is a paucity of evidence to support the routine use of chest radiography. Additionally, lack of certain signs and symptoms may obviate the need for chest radiography in the evaluation for other concerning causes of chest pain. Chest radiographs are very useful at times but are found to be unremarkable the vast majority of the time. A clinical decision rule (CDR) for the use of chest radiography in patients presenting with nontraumatic chest pain could reduce the use of chest radiography, enhance ED throughput, decrease costs, and decrease radiation exposure. Several recent studies have attempted to identify the signs and symptoms associated with abnormal and

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