突破性心衰竭診斷:REFER研究提高初級醫療診斷精準度

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REFER研究探討了臨床決策規則(CDR)與N末端前腦利鈉肽(NT-proBNP)檢測在識別心衰竭方面的效能。在對28個英國一般醫療診所的>55歲病患進行前瞻性觀察後發現,NT-proBNP檢測的低閾值(<125 pg/ml)比結合CDR更有效,但400 pg/ml的高閾值可能會導致超過五分之一的心衰竭病患未能得到適當轉診。研究建議可能需重新審視指南中的利鈉肽閾值。

初級保健心力衰竭回聲心電圖轉診(REFER):一項診斷準確性研究

Primary care REFerral for EchocaRdiogram (REFER) in heart failure: a diagnostic accuracy study

Taylor CJ, Roalfe AK, Iles R, Hobbs FR; REFER investigators; Barton P, Deeks J, McCahon D, Cowie MR, Sutton G, Davis RC, Mant J, McDonagh T, Tait L. Primary care REFerral for EchocaRdiogram (REFER) in heart failure: a diagnostic accuracy study. Br J Gen Pract. 2017 Feb;67(655):e94-e102. doi: 10.3399/bjgp16X688393. Epub 2016 Dec 5. PMID: 27919937; PMCID: PMC5308123.

https://pubmed.ncbi.nlm.nih.gov/27919937/

Abstract

Background

Symptoms of breathlessness, fatigue, and ankle swelling are common in general practice but deciding which patients are likely to have heart failure is challenging.

Aim

To evaluate the performance of a clinical decision rule (CDR), with or without N-Terminal pro-B type natriuretic peptide (NT-proBNP) assay, for identifying heart failure.

Design and setting

Prospective, observational, diagnostic validation study of patients aged >55 years, presenting with shortness of breath, lethargy, or ankle oedema, from 28 general practices in England.

Method

The outcome was test performance of the CDR and natriuretic peptide test in determining a diagnosis of heart failure. The reference standard was an expert consensus panel of three cardiologists.

Results

Three hundred and four participants were recruited, with 104 (34.2%; 95% confidence interval [CI] = 28.9 to 39.8) having a confirmed diagnosis of heart failure. The CDR+NT-proBNP had a sensitivity of 90.4% (95% CI = 83.0 to 95.3) and specificity 45.5% (95% CI = 38.5 to 52.7). NT-proBNP level alone with a cut-off <400 pg/ml had sensitivity 76.9% (95% CI = 67.6 to 84.6) and specificity 91.5% (95% CI = 86.7 to 95.0). At the lower cut-off of NT-proBNP <125 pg/ml, sensitivity was 94.2% (95% CI = 87.9 to 97.9) and specificity 49.0% (95% CI = 41.9 to 56.1).

Conclusion

At the low threshold of NT-proBNP <125 pg/ml, natriuretic peptide testing alone was better than a validated CDR+NT-proBNP in determining which patients presenting with symptoms went on to have a diagnosis of heart failure. The higher NT-proBNP threshold of 400 pg/ml may mean more than one in five patients with heart failure are not appropriately referred. Guideline natriuretic peptide thresholds may need to be revised.

Keywords

clinical decision rule; diagnostic; echocardiography; general practice; heart failure; natriuretic peptide.

摘要

背景

在一般診所中,呼吸急促、疲勞和腳踝腫脹的症狀很常見,但要決定哪些患者可能患有心力衰竭是一個挑戰。

目的

評估臨床決策規則(CDR)的表現,無論是否配合N末端前體B型利尿肽(NT-proBNP)檢測,用於識別心力衰竭。

設計與背景

這是一項對於年齡超過55歲、因呼吸急促、乏力或腳踝水腫來到英格蘭28家一般診所的患者所進行的前瞻性、觀察性、診斷驗證研究。

方法

研究結果是CDR和利尿肽檢測在確定心力衰竭診斷上的表現。參考標準是由三名心臟病專家組成的專家共識小組。

結果

共招募了304名參與者,其中104人(34.2%;95%信賴區間[CI] = 28.9至39.8)確診患有心力衰竭。CDR+NT-proBNP的敏感性為90.4%(95% CI = 83.0至95.3),特異性為45.5%(95% CI = 38.5至52.7)。僅使用NT-proBNP檢測,且閾值低於400 pg/ml時,敏感性為76.9%(95% CI = 67.6至84.6),特異性為91.5%(95% CI = 86.7至95.0)。在NT-proBNP <125 pg/ml的更低閾值下,敏感性為94.2%(95% CI = 87.9至97.9),特異性為49.0%(95% CI = 41.9至56.1)。

結論

在NT-proBNP <125 pg/ml的低閾值下,僅進行利尿肽檢測比驗證過的CDR+NT-proBNP更能準確判斷出現症狀的患者是否最終被診斷為心力衰竭。更高的NT-proBNP閾值400 pg/ml可能意味著超過五分之一的心力衰竭患者未被適當轉診。利尿肽檢測的指南閾值可能需要修訂。

關鍵詞

臨床決策規則;診斷;心臟超聲檢查;一般診所;心力衰竭;利尿肽。

圖1

示意REFER研究參與者人數的流程圖。步驟1 = 臨床資訊+心電圖+心臟超聲波。步驟2 = CDR變量。步驟3 = NT–proBNP結果。CDR = 臨床決策規則。DNA = 未參加。NT-proBNP = N末端前體B型利尿肽水平。

圖2

 預測心力衰竭的CDR+NT-proBNP或僅NT-proBNP的接收者操作特徵曲線。CDR = 臨床決策規則。NT-proBNP = N末端前體B型利尿肽水平。