Atzema Clare, Schull Michael J, Borgundvaag Bjug, Slaughter Graham R D, Lee Cheong K
Division of Emergency Medicine, Sunnybrook and Women's College Health Sciences Centre, Toronto, ON, Canada.
Am J Emerg Med. 2006 Jan;24(1):62-7. doi: 10.1016/j.ajem.2005.05.015.
Current guidelines suggest that most patients who present to an emergency department (ED) with chest pain should be placed on a continuous electrocardiographic monitoring (CEM) device. We evaluated the utility of CEM in ED patients with chest pain.
We enrolled stable patients who presented to a single ED with chest pain suspected to be ischemic in origin and who were placed on CEM. Patients were classified according to risk of poor outcome using 3 published stratification tools. Trained observers prospectively recorded number of monitored hours, alarms, changes in management, and monitor-detected adverse events (AEs). The primary outcome measure was the rate of AEs detected by CEM. Secondary outcome measures were the rate of alarms that resulted in a change in management and number of false alarms.
We enrolled 72 patients, 56% of whom were categorized as very low-risk by Goldman risk criteria. During 371 monitored hours, we recorded 1762 alarms or 4.7 alarms per monitored hour. There were 11 AEs (0.68%; 95% CI, 0.35%-1.2%), 3 of which resulted in a change in management (0.2%; 95% CI, 0.04%-0.5%). Seven AEs were bradydysrhythmias with a heart rate of 45 or higher; the eighth patient had no change in symptoms and was given atropine for a heart rate of 32. The other 3 AEs were an untreated supraventricular tachycardia, a brief sinus pause that triggered a rate change in intravenous nitroglycerin by the patient's nurse, and a run of premature ventricular contractions after which heparin was administered. None of the 3 patients with a change in management was categorized as the lowest-risk.
Routine CEM in low-risk ED patients with chest pain results in an excessive number of alarms, most of which require no change in management. In these patients, the benefit of CEM may be limited, and given that 99.4% of alarms were false, current CEM technology needs to be improved.
当前指南建议，大多数因胸痛就诊于急诊科（ED）的患者应使用连续心电图监测（CEM）设备。我们评估了CEM在ED胸痛患者中的效用。
我们纳入了因疑似缺血性胸痛就诊于单一急诊科且接受CEM监测的稳定患者。使用3种已发表的分层工具根据不良结局风险对患者进行分类。经过培训的观察者前瞻性记录监测小时数、警报次数、管理措施的改变以及监测仪检测到的不良事件（AE）。主要结局指标是CEM检测到的AE发生率。次要结局指标是导致管理措施改变的警报发生率和误报次数。
我们纳入了72例患者，根据Goldman风险标准，其中56%被归类为极低风险。在371个监测小时内，我们记录了1762次警报，即每监测小时4.7次警报。有11次AE（0.68%；95%CI，0.35%-1.2%），其中3次导致管理措施改变（0.2%；95%CI，0.04%-0.5%）。7次AE为心率45次或更高的缓慢性心律失常；第8例患者症状无变化，因心率32次而给予阿托品治疗。其他3次AE分别为1例未治疗的室上性心动过速、1例短暂窦性停搏导致患者护士改变静脉硝酸甘油滴注速度以及1次室性早搏连发后给予肝素治疗。3例管理措施改变的患者均未被归类为最低风险。
对低风险ED胸痛患者进行常规CEM会导致过多警报，其中大多数不需要改变管理措施。在这些患者中，CEM的益处可能有限，鉴于99.4%的警报为误报，当前的CEM技术需要改进。
