Meyer Mary C, Mooney Robert P, Sekera Anna K
Department of Emergency Medicine, Kaiser Permanente Medical Center, Walnut Creek, CA 94696, USA.
Ann Emerg Med. 2006 May;47(5):427-35. doi: 10.1016/j.annemergmed.2005.10.010. Epub 2006 Feb 8.
We evaluate the safety and feasibility of a critical care pathway protocol in which patients with acute chest pain who are low risk for coronary artery disease and short-term adverse cardiac outcomes receive outpatient stress testing within 72 hours of an emergency department (ED) visit.
We performed an observational study of an ED-based chest pain critical pathway in an urban, community hospital in 979 consecutive patients. Patients enrolled in the protocol were observed in the ED before receiving 72-hour outpatient stress testing. The pathway was primarily analyzed for rates of death or myocardial infarction in the 6 months after ED discharge and outpatient stress testing. Secondary outcome measures included need for coronary intervention at initial stress testing and within 6 months after discharge, subsequent ED visits for chest pain, and subsequent hospitalization.
Of 871 stress-tested patients aged 40 years or older, who had low risk for coronary artery disease and short-term adverse cardiac events, and had 6-month follow-up, 18 (2%) required coronary intervention, 1 (0.1%) had a myocardial infarction within 1 month, 2 (0.2%) had a myocardial infarction within 6 months, 6 (0.7%) had normal stress test results after discharge but required cardiac catheterization within 6 months, and 5 (0.6%) returned to the ED within 6 months for ongoing chest pain. Hospital admission rates decreased significantly from 31.2% to 26.1% after initiation of the protocol (P<.001).
For patients with chest pain and low risk for short-term cardiac events, outpatient stress testing is feasible, safe, and associated with decreased hospital admission rates. With an evidence-based protocol, physicians efficiently identify patients at low risk for clinically significant coronary artery disease and short-term adverse cardiac outcomes.
我们评估一种重症监护路径方案的安全性和可行性，该方案针对冠状动脉疾病风险低且短期心脏不良结局风险低的急性胸痛患者，在急诊科（ED）就诊后72小时内进行门诊负荷试验。
我们在一家城市社区医院对基于急诊科的胸痛关键路径进行了一项观察性研究，纳入了979例连续患者。纳入该方案的患者在接受72小时门诊负荷试验前在急诊科接受观察。主要分析该路径在急诊科出院和门诊负荷试验后6个月内的死亡率或心肌梗死发生率。次要结局指标包括初始负荷试验时及出院后6个月内进行冠状动脉介入治疗的必要性、随后因胸痛到急诊科就诊的情况以及随后的住院情况。
在871例年龄40岁及以上、冠状动脉疾病风险低且短期心脏不良事件风险低且有6个月随访的接受负荷试验的患者中，18例（2%）需要冠状动脉介入治疗，1例（0.1%）在1个月内发生心肌梗死，2例（0.2%）在6个月内发生心肌梗死，6例（0.7%）出院后负荷试验结果正常但在6个月内需要进行心导管检查，5例（0.6%）在6个月内因持续胸痛返回急诊科。该方案启动后，住院率从31.2%显著降至26.1%（P<0.001）。
对于胸痛且短期心脏事件风险低的患者，门诊负荷试验是可行、安全的，且与住院率降低相关。通过基于证据的方案，医生能够有效地识别冠状动脉疾病临床显著风险低且短期心脏不良结局风险低的患者。
