Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health
Validation of a Decision Rule for Selective TSH Screening in Atrial Fibrillation
- Author(s): Bellew, Shawna D.
- Moman, Rajat
- Lohse, Christine M.
- Hess, Erik P
- Bellolio, M. Fernanda
- et al.
Published Web Locationhttps://doi.org/10.5811/westjem.2014.11.23490
Introduction: Atrial fibrillation (AF) is the most common cardiac dysrhythmia. Current guidelines recommend obtaining thyroid-stimulating hormone (TSH) levels in all patients presenting with AF.Our aim was to investigate the utility of TSH levels for emergency department (ED) patients with a final diagnosis of AF while externally validating and potentially refining a clinical decision rule that recommends obtaining TSH levels only in patients with previous stroke, hypertension, or thyroid disease.
Methods: We conducted a retrospective, cross-sectional study of consecutive patients who presented to an ED from January 2011 to March 2014 with a final ED diagnosis of AF. Charts were reviewed for historical features and TSH level. We assessed the sensitivity and specificity of the previously derived clinical decision rule.
Results: Of the 1,964 patients who were eligible, 1,458 (74%) had a TSH level available for analysis. The overall prevalence of a low TSH (<0.3µIU/mL) was 2% (n=36). Elevated TSH levels (>5µIU/mL) were identified in 11% (n=159). The clinical decision rule had a sensitivity of 88.9% (95% CI [73.0-96.4]) and a specificity of 27.5% (95% CI [25.2-29.9]) for identifying a low TSH. When analyzed for its ability to identify any abnormal TSH values (high or low TSH), the sensitivity and specificity were 74.4% (95% CI [67.5-80.2]) and 27.3% (95% CI [24.9-29.9]), respectively.
Conclusion: Low TSH in patients presenting to the ED with a final diagnosis of AF is rare (2%). The sensitivity of a clinical decision rule including a history of thyroid disease, hypertension, or stroke for identifying low TSH levels in patients presenting to the ED with a final diagnosis of atrial fibrillation was lower than originally reported (88.9% vs. 93%). When elevated TSH levels were included as an outcome, the sensitivity was reduced to 74.4%. We recommend that emergency medicine providers not routinely order TSH levels for all patients with a primary diagnosis of AF. Instead, these investigations can be limited to patients with new onset AF or those with a history of thyroid disease with no known TSH level within three months . [West J Emerg Med. 2015;16(1):–0.]