- 作者：Jesse M. Pines ; Demian Szyld
- 关键词：Acetic acid (AA) ; Hematuria ; Hemolysis ; Hepatic dysfunction
- 刊名：The American Journal of Emergency Medicine
- 出版年：2007
- 出版时间：June 2007
- 年：2007
- 卷：25
- 期：5
- 页码：540-544
- 全文大小：118 K
Methods
Published guidelines that make practice recommendations on the evaluation of ACS, PE, and SAH were sought using the National Guideline Clearinghouse in low-risk settings. Second-order Monte Carlo simulation was performed to determine point estimates and confidence intervals (CIs) for posttest probabilities assuming a pretest probability of 10 % .
Results
Guidelines recommend that patients with low-risk suspected ACS should undergo stress testing. For SAH, computed tomography (CT) followed by lumbar puncture (LP) is recommended without mention of pretest probability; and D-dimer testing is recommended to exclude PE in low-risk patients. Test sensitivity for thallium-201 single photon emission computed tomography (SPECT) was 89 % , exercise echocardiogram was 85 % , D-dimer testing was 95 % , and CT/LP for SAH was 100 % (as a gold standard) and CT only was 97.5 % . Given a negative test result, for PE, posttest probability was 0.5 % (95 % CI 0.1 % -0.9 % ); for SPECT, 1.1 % (SD 0.5 % -1.6 % ); and for exercise echocardiogram, 1.5 % (95 % CI 0.5 % -2.5 % ) compared with a posttest probability of 0 % for CT followed by LP for SAH. Using a CT-only approach gives a posttest probability of 0.2 % (95 % CI 0.2 % -0.4 % ).
Conclusions
Guidelines for suspected PE and ACS allow small but nonzero calculated risk end points in low-risk settings, whereas SAH guidelines afford no misses. Because many gold standard tests are more invasive and can have adverse effects, guideline authors should consider adopting a standard acceptable miss rate as an end point for workups with low clinical suspicion to avoid the overuse of invasive testing.