Limkakeng A, Gibler W B, Pollack C, Hoekstra J W, Sites F, Shofer F S, Tiffany B, Wilke E, Hollander J E
Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA 19104-4283, USA.
Acad Emerg Med. 2001 Jul;8(7):696-702. doi: 10.1111/j.1553-2712.2001.tb00187.x.
Accurate identification of low-risk emergency department (ED) chest pain patients who may be safe for discharge has not been well defined. Goldman criteria have reliably risk-stratified patients but have not identified any subset safe for ED release. Cardiac troponin I (cTnI) values have also been shown to risk-stratify patients but have not identified a subset safe for ED release.
To test the hypothesis that ED chest pain patients with a Goldman risk of < or =4% and a single negative cTnI (< or =0.3 ng/mL) at the time of ED presentation would be safe for discharge [<1% risk for death, acute myocardial infarction (AMI), revascularization].
A prospective cohort study was performed in which consecutive ED chest pain patients were enrolled from July 1999 to November 2000. Data collected included patient demographics, medical and cardiac history, electrocardiogram, and creatine kinase-MB and cTnI. Goldman risk stratification score was calculated while patients were still in the ED. Hospital course was followed daily. Telephone follow-up occurred at 30 days. The main outcome was death, AMI, or revascularization (percutaneous transluminal coronary angioplasty/stents/coronary artery bypass grafting) within 30 days.
Of 2,322 patients evaluated, 998 had both a Goldman risk < or =4% and a cTnI < or =0.3 ng/mL. During the initial hospitalization, 37 patients met the composite endpoint (3.7%): 6 deaths (0.7%), 17 AMIs (1.7%), 18 revascularizations (1.8%). Between the time of hospital discharge and 30-day follow-up, 15 patients met the composite endpoint: 4 deaths (0.4%), 6 AMIs (0.6%), and 5 revascularizations (0.5%). Overall, 49 patients met the composite endpoint (4.9%; 95% CI = 3.6% to 6.2%): 10 deaths (1.0%; 95% CI = 0.4% to 1.6%); 23 AMIs (2.3%; 95% CI = 1.4% to 3.2%), and 23 revascularizations (2.3%; 95% CI = 1.4% to 3.2%) within 30 days of presentation.
The combination of two risk stratification modalities for ED chest pain patients (Goldman risk < or =4% and cTnI < or =0.3 ng/mL) did not identify a subgroup of chest pain patients at <1% risk for death, AMI, or revascularization within 30 days.
准确识别可能安全出院的低风险急诊科胸痛患者尚未得到明确界定。戈德曼标准已可靠地对患者进行风险分层，但尚未识别出任何可安全从急诊科出院的亚组。心肌肌钙蛋白I（cTnI）值也已被证明可对患者进行风险分层，但尚未识别出可安全从急诊科出院的亚组。
检验以下假设，即急诊科就诊时戈德曼风险≤4%且单次cTnI阴性（≤0.3 ng/mL）的胸痛患者可安全出院[死亡、急性心肌梗死（AMI）、血运重建风险<1%]。
进行了一项前瞻性队列研究，1999年7月至2000年11月连续纳入急诊科胸痛患者。收集的数据包括患者人口统计学、病史和心脏病史、心电图以及肌酸激酶同工酶和cTnI。在患者仍在急诊科时计算戈德曼风险分层评分。每天跟踪住院过程。30天时进行电话随访。主要结局是30天内死亡、AMI或血运重建（经皮腔内冠状动脉成形术/支架/冠状动脉旁路移植术）。
在评估的2322例患者中，998例戈德曼风险≤4%且cTnI≤0.3 ng/mL。在初次住院期间，37例患者达到复合终点（3.7%）：6例死亡（0.7%），17例AMI（1.7%），18例血运重建（1.8%）。在出院至30天随访期间，15例患者达到复合终点：4例死亡（0.4%），6例AMI（0.6%），5例血运重建（0.5%）。总体而言，49例患者达到复合终点（4.9%；95%CI = 3.6%至6.2%）：10例死亡（1.0%；95%CI = 0.4%至1.6%）；23例AMI（2.3%；95%CI = 1.4%至3.2%），23例血运重建（2.3%；95%CI = 1.4%至3.2%），均在就诊后30天内。
对于急诊科胸痛患者，两种风险分层方式（戈德曼风险≤4%且cTnI≤0.3 ng/mL）的联合并未识别出30天内死亡、AMI或血运重建风险<1%的胸痛患者亚组。
