Udelson James E, Beshansky Joni R, Ballin Daniel S, Feldman James A, Griffith John L, Handler Jonathan, Heller Gary V, Hendel Robert C, Pope J Hector, Ruthazer Robin, Spiegler Ethan J, Woolard Robert H, Selker Harry P
Division of Clinical Care Research, Tufts-New England Medical Center, 750 Washington St, Box 70, Boston, MA 02111, USA.
JAMA. 2002 Dec 4;288(21):2693-700. doi: 10.1001/jama.288.21.2693.
CONTEXT: Observational studies of acute myocardial perfusion imaging in emergency department (ED) patients with chest pain have suggested high sensitivity and negative predictive value for acute cardiac ischemia, but use of this method has not been prospectively tested. OBJECTIVE: To assess whether incorporating acute resting perfusion imaging into an ED evaluation strategy for patients with suspected acute ischemia but no initial electrocardiogram (ECG) changes diagnostic of acute ischemia improves clinical decision making for initial ED triage. DESIGN, SETTING, AND PATIENTS: Prospective, randomized controlled trial conducted at 7 academic medical centers and community hospitals between July 1997 and May 1999 among 2475 adult ED patients with chest pain or other symptoms suggestive of acute cardiac ischemia and with normal or nondiagnostic initial ECG results. INTERVENTION: Patients were randomly assigned to receive either the usual ED evaluation strategy (n = 1260) or the usual strategy supplemented with results from acute resting myocardial perfusion imaging using single-photon emission computed tomography with injection of 20 to 30 mCi of Tc-99m sestamibi (n = 1215), interpreted in real time by local staff physicians and with results provided to the ED physician for incorporation into clinical decision making. MAIN OUTCOME MEASURE: Appropriateness of triage decision either to admit to hospital/observation or to discharge directly home from the ED. RESULTS: Among patients with acute cardiac ischemia (ie, acute myocardial infarction [MI] or unstable angina; n = 329), there were no differences in ED triage decisions between those receiving standard evaluation and those whose evaluation was supplemented by a sestamibi scan. Among patients with acute MI (n = 56), 97% vs 96% were hospitalized (relative risk [RR], 1.00; 95% confidence interval [CI], 0.89-1.12), and among those with unstable angina (n = 273), 83% vs 81% were hospitalized (RR, 0.98; 95% CI, 0.87-1.10). However, among patients without acute cardiac ischemia (n = 2146), hospitalization was 52% with usual care vs 42% with sestamibi imaging (RR, 0.84; 95% CI, 0.77-0.92). CONCLUSIONS: Sestamibi perfusion imaging improves ED triage decision making for patients with symptoms suggestive of acute cardiac ischemia without obvious abnormalities on initial ECG. In this study, unnecessary hospitalizations were reduced among patients without acute ischemia, without reducing appropriate admission for patients with acute ischemia.
背景：针对急诊科（ED）胸痛患者的急性心肌灌注成像观察性研究表明，该方法对急性心肌缺血具有较高的敏感性和阴性预测价值，但尚未对该方法进行前瞻性测试。 目的：评估将急性静息灌注成像纳入疑似急性缺血但初始心电图（ECG）无急性缺血诊断性改变患者的ED评估策略，是否能改善ED初始分诊的临床决策。 设计、地点和患者：1997年7月至1999年5月在7家学术医疗中心和社区医院进行的前瞻性随机对照试验，纳入2475例成年ED胸痛患者或有其他提示急性心肌缺血症状且初始ECG结果正常或无诊断意义的患者。 干预措施：患者被随机分配接受常规ED评估策略（n = 1260）或常规策略辅以使用单光子发射计算机断层扫描并注射20至30 mCi的锝-99m甲氧基异丁基异腈进行急性静息心肌灌注成像的结果（n = 1215），由当地主治医师实时解读，并将结果提供给ED医师以纳入临床决策。 主要观察指标：分诊决定的适宜性，即是否收住入院/观察或直接从ED出院回家。 结果：在急性心肌缺血患者（即急性心肌梗死[MI]或不稳定型心绞痛；n = 329）中，接受标准评估的患者与接受甲氧基异丁基异腈扫描补充评估的患者在ED分诊决定上无差异。在急性MI患者（n = 56）中，住院率分别为97%和96%（相对危险度[RR]，1.00；95%置信区间[CI]，0.89 - 1.12），在不稳定型心绞痛患者（n = 273）中，住院率分别为83%和81%（RR，0.98；95% CI，0.87 - 1.10）。然而，在无急性心肌缺血的患者（n = 2146）中，常规治疗组的住院率为52%，甲氧基异丁基异腈成像组为42%（RR，0.84；95% CI，0.77 - 0.92）。 结论：甲氧基异丁基异腈灌注成像可改善对有急性心肌缺血症状但初始ECG无明显异常患者的ED分诊决策。在本研究中，无急性缺血患者的不必要住院率降低了，同时未减少急性缺血患者的适当入院率。
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