Hollander Judd E, Sites Frank D, Pollack Charles V, Shofer Frances S
Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia 19104-4283, USA.
Ann Emerg Med. 2004 Jan;43(1):71-6. doi: 10.1016/s0196-0644(03)00719-4.
Low-risk patients with chest pain are often admitted to monitored beds; however, the use of telemetry beds in this cohort is not evidence based. We tested the hypothesis that monitoring admitted low-risk patients with chest pain for dysrhythmia is low yield (<1% detection of life-threatening dysrhythmias requiring treatment).
We conducted a prospective cohort study of emergency department (ED) patients with chest pain with a Goldman risk score of less than 8%, a normal initial creatine kinase-MB level, and a negative initial troponin I level admitted to non-ICU monitored beds. Investigators followed the hospital course daily. The main outcome was cardiovascular death and life-threatening ventricular dysrhythmia during telemetry.
Of 3,681 patients with chest pain who presented to the ED, 1,750 patients were admitted to non-ICU monitored beds. Of these, 1,029 patients had a Goldman risk score of less than 8%, a troponin I level of less than 0.3 ng/mL, and a creatine kinase-MB level of less than 5 ng/mL (accounting for 59% of all chest pain telemetry admissions). During hospitalization, there were no patients with sustained ventricular tachycardia/ventricular fibrillation requiring treatment on the telemetry service (0%; 95% confidence interval [CI] 0% to 0.3%). There were 2 deaths: neither was cardiovascular in nature or preventable by monitoring (cardiovascular preventable death rate=0%; 95% CI 0.0% to 0.3%).
The routine use of telemetry monitoring for low-risk patients with chest pain is of limited utility. Admission to nonmonitored beds might help alleviate ED crowding without increasing risk of adverse events caused by dysrhythmia in patients with a Goldman risk of less than 8%, an initial troponin I level of less than 0.3 ng/mL, and a creatine kinase-MB level of less than 5 ng/mL.
低风险胸痛患者常被收治于监护病房；然而，在这一人群中使用遥测监护床并无循证依据。我们检验了这样一个假设，即对收治的低风险胸痛患者进行心律失常监测的收益较低（发现需要治疗的危及生命的心律失常的比例<1%）。
我们对急诊科胸痛患者进行了一项前瞻性队列研究，这些患者的戈德曼风险评分低于8%，初始肌酸激酶-MB水平正常，初始肌钙蛋白I水平为阴性，被收治于非重症监护病房的监护床位。研究人员每天跟踪患者的住院病程。主要结局是遥测监护期间的心血管死亡和危及生命的室性心律失常。
在3681例到急诊科就诊的胸痛患者中，1750例被收治于非重症监护病房的监护床位。其中，1029例患者的戈德曼风险评分低于8%，肌钙蛋白I水平低于0.3 ng/mL，肌酸激酶-MB水平低于5 ng/mL（占所有胸痛遥测监护收治患者的59%）。住院期间，遥测监护服务中没有患者出现需要治疗的持续性室性心动过速/心室颤动（0%；95%置信区间[CI]为0%至0.3%）。有2例死亡：均非心血管原因导致，也无法通过监测预防（心血管可预防死亡率=0%；95%CI为0.0%至0.3%）。
对低风险胸痛患者常规使用遥测监护的作用有限。对于戈德曼风险低于8%、初始肌钙蛋白I水平低于0.3 ng/mL且肌酸激酶-MB水平低于5 ng/mL的患者，收治于非监护床位可能有助于缓解急诊科拥挤状况，且不会增加心律失常导致不良事件的风险。
