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Development and external validation of new nomograms by adding ECG changes (ST depression or tall T wave) and age to conventional scoring systems to improve the predictive capacity in patients with subarachnoid haemorrhage: a retrospective, observational study in Korea

 Ju young Hong  ;  Je Sung You  ;  Min Joung Kim  ;  Hye Sun Lee  ;  Yoo Seok Park  ;  Sung Phil Chung  ;  Incheol Park 
 BMJ Open, Vol.9(2) : e024007, 2019 
Journal Title
 BMJ Open 
Issue Date
electrocardiogram ; emergency department ; nomogram ; prognosis ; subarachnoid haemorrhage
OBJECTIVES: To develop new nomograms by adding ECG changes (ST depression or tall T wave) and age to three conventional scoring systems, namely, World Federation of Neurosurgical Societies (WFNS) scale, Hunt and Hess (HH) system and Fisher scale, that can predict prognosis in patients with subarachnoid haemorrhage (SAH) using our preliminary research results and to perform external validation of the three new nomograms. DESIGN: Retrospective, observational study SETTING: Emergency departments (ED) of two university-affiliated tertiary hospital between January 2009 and March 2015. PARTICIPANTS: Adult patients with SAH were enrolled. Exclusion criteria were age <19 years, no baseline ECG, cardiac arrest on arrival, traumatic SAH, referral from other hospital and referral to other hospitals from the ED. PRIMARY OUTCOME MEASURES: The 6 month prognosis was assessed using the Glasgow Outcome Scale (GOS). We defined a poor outcome as a GOS score of 1, 2 or 3. RESULTS: A total of 202 patients were included for analysis. From the preliminary study, age, ECG changes (ST depression or tall T wave), and three conventional scoring systems were selected to predict prognosis in patients with SAH using multi-variable logistic regression. We developed simplified nomograms using these variables. Discrimination of the developed nomograms including WFNS scale, HH system and Fisher scale was superior to those of WFNS scale, HH system and Fisher scale (0.912 vs 0.813; p<0.001, 0.913 vs 0.826; p<0.001, and 0.885 vs 0.746; p<0.001, respectively). The calibration plots showed excellent agreement. In the external validation, the discrimination of the newly developed nomograms incorporating the three scoring systems was also good, with an area under the receiver-operating characteristic curve value of 0.809, 0.812 and 0.772, respectively. CONCLUSIONS: We developed and externally validated new nomograms using only three independent variables. Our new nomograms were superior to the WFNS scale, HH systems, and Fisher scale in predicting prognosis and are readily available.
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1. College of Medicine (의과대학) > Dept. of Emergency Medicine (응급의학교실) > 1. Journal Papers
1. College of Medicine (의과대학) > Yonsei Biomedical Research Center (연세의생명연구원) > 1. Journal Papers
Yonsei Authors
김민정(Kim, Min Joung) ORCID logo https://orcid.org/0000-0003-1634-5209
박유석(Park, Yoo Seok) ORCID logo https://orcid.org/0000-0003-1543-4664
박인철(Park, In Cheol) ORCID logo https://orcid.org/0000-0001-7033-766X
유제성(You, Je Sung) ORCID logo https://orcid.org/0000-0002-2074-6745
이혜선(Lee, Hye Sun) ORCID logo https://orcid.org/0000-0001-6328-6948
정성필(Chung, Sung Pil) ORCID logo https://orcid.org/0000-0002-3074-011X
홍주영(Hong, Ju Young) ORCID logo https://orcid.org/0000-0003-3416-3054
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