The diagnostic accuracy of cardiac ultrasound for acute myocardial ischemia in the emergency department: a systematic review and meta-analysis

Virginia Zarama, María Camila Arango-Granados, Ramiro Manzano-Nunez, James P. Sheppard, Nia Roberts, Annette Plüddemann
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Abstract

Chest pain is responsible for millions of visits to the emergency department (ED) annually. Cardiac ultrasound can detect ischemic changes, but varying accuracy estimates have been reported in previous studies. We synthetized the available evidence to yield more precise estimates of the accuracy of cardiac ultrasound for acute myocardial ischemia in patients with chest pain in the ED and to assess the effect of different clinical characteristics on test accuracy. A systematic search for studies assessing the diagnostic accuracy of cardiac ultrasound for myocardial ischemia in the ED was conducted in MEDLINE, EMBASE, CENTRAL, CINAHL, LILACS, Web of Science, two trial registries and supplementary methods, from inception to December 6th, 2022. Prospective cohort, cross-sectional, case–control studies and randomized controlled trials (RCTs) that included data on diagnostic accuracy were included. Risk of bias was assessed with the QUADAS-2 tool and a bivariate hierarchical model was used for meta-analysis with paired Forest and SROC plots used to present the results. Subgroup analyses was conducted on clinically relevant factors. Twenty-nine studies were included, with 5043 patients. The overall summary sensitivity was 79.3% (95%CI 69.0–86.8%) and specificity was 87.3% (95%CI 79.9–92.2%), with substantial heterogeneity. Subgroup analyses showed increased sensitivity in studies where ultrasound was conducted at ED admission and increased specificity in studies that excluded patients with previous heart disease, when the target condition was acute coronary syndrome, or when final chart review was used as the reference standard. There was very low certainty in the results based on serious risk of bias and indirectness in most studies. Cardiac ultrasound may have a potential role in the diagnostic pathway of myocardial ischemia in the ED; however, a pooled accuracy must be interpreted cautiously given substantial heterogeneity and that important patient and test characteristics affect its diagnostic performance. Protocol Registration: PROSPERO (CRD42023392058).
急诊科急性心肌缺血的心脏超声诊断准确性:系统回顾和荟萃分析
每年有数百万人因胸痛到急诊科(ED)就诊。心脏超声能检测出缺血性病变,但以往的研究对其准确性的估计各不相同。我们对现有证据进行了综合分析,以便更精确地估计心脏超声对急诊科胸痛患者急性心肌缺血的准确性,并评估不同临床特征对检测准确性的影响。从开始到 2022 年 12 月 6 日,我们在 MEDLINE、EMBASE、CENTRAL、CINAHL、LILACS、Web of Science、两个试验登记处和补充方法中对评估急诊室心肌缺血心脏超声诊断准确性的研究进行了系统检索。研究纳入了包含诊断准确性数据的前瞻性队列研究、横断面研究、病例对照研究和随机对照试验(RCT)。使用 QUADAS-2 工具评估偏倚风险,并使用双变量分层模型进行荟萃分析,同时使用配对森林图和 SROC 图来显示结果。对临床相关因素进行了分组分析。共纳入 29 项研究,5043 名患者。总体汇总灵敏度为 79.3%(95%CI 69.0-86.8%),特异性为 87.3%(95%CI 79.9-92.2%),异质性很大。亚组分析显示,在急诊室入院时进行超声检查的研究灵敏度更高,而在排除既往心脏病患者、目标病症为急性冠脉综合征或将最终病历审查作为参考标准的研究中,特异性更高。由于大多数研究存在严重的偏倚风险和间接性,因此研究结果的确定性很低。心脏超声可能在急诊室心肌缺血的诊断过程中发挥潜在作用;但是,由于存在大量异质性,而且重要的患者和测试特征会影响其诊断性能,因此必须谨慎解释汇总的准确性。协议注册:prospero(CRD42023392058)。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
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