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

Clare J Taylor 1, Andrea K Roalfe 2, Rachel Iles 2, Fd Richard Hobbs 1; REFER investigators; P Barton 2, J Deeks 2, D McCahon 2, M R Cowie 3, G Sutton 3, R C Davis 4, J Mant 5, T McDonagh 6, L Tait 7
Affiliations expand
PMID: 27919937 PMCID: PMC5308123 DOI: 10.3399/bjgp16X688393

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

Abstract

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

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.

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.

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.

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).

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.

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

摘要

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。

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。

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。

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。

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）。

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。

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。