Rubinshtein Ronen, Halon David A, Kogan Asia, Jaffe Ronen, Karkabi Basheer, Gaspar Tamar, Flugelman Moshe Y, Shapira Reuma, Merdler Amnon, Lewis Basil S
Department of Cardiovascular Medicine, Carmel Medical Center, Haifa, Israel.
Isr Med Assoc J. 2006 May;8(5):329-32.
Emergency room triage of patients presenting with chest pain syndromes may be difficult. Under-diagnosis may be dangerous, while over-diagnosis may be costly.
To report our initial experience with an emergency room cardiologist-based chest pain unit in Israel.
During a 5 week pilot study, we examined resource utilization and ER diagnosis in 124 patients with chest pain of uncertain etiology or non-high risk acute coronary syndrome. First assessment was performed by the ER physicians and was followed by a second assessment by the CPU team. Assessment was based on the following parameters: medical history and examination, serial electrocardiography, hematology, biochemistry and biomarkers for ACS, exercise stress testing and/or 64-slice multi-detector cardiac computed tomography angiography. Changes in decision between initial assessment and final CPU assessment with regard to hospitalization and utilization of resources were recorded.
All patients had at least two cardiac troponin T measurements, 19 underwent EST, 9 echocardiography and 29 cardiac MDCT. Fourteen patients were referred for early cardiac catheterization (same/next day). A specific working diagnosis was reached in 71/84 patients hospitalized, including unstable angina in 39 (31%) and non-ST elevation myocardial infarction in 12 (10%). Following CPU assessment, 40/124 patients (32%) were discharged, 49 (39%) were admitted to Internal Medicine and 35 (28%) to the Cardiology departments. CPU assessment and extended resources allowed discharge of 30/101 patients (30%) who were initially identified as candidates for hospitalization after ER assessment. Furthermore, 13/23 patients (56%) who were candidates for discharge after initial ER assessment were eventually hospitalized. Use of non-invasive tests was significantly greater in patients discharged from the ER (85% vs. 38% patients hospitalized) (P < 0.0001). The mean ER stay tended to be longer (14.9 +/- 8.6 hours vs. 12.9 +/- 11, P = NS) for patients discharged. At 30 days follow-up, there were no adverse events (myocardial infarction or death) in any of the 40 patients discharged from the ER after CPU assessment. One patient returned to the ER because of chest pain and was discharged after reassessment.
Our initial experience showed that an ER cardiologist-based chest pain unit improved assessment of patients presenting to the ER with chest pain, and enhanced appropriate use of diagnostic tests prior to a decision regarding admission/discharge from the ER.
对出现胸痛综合征的患者进行急诊室分诊可能具有挑战性。诊断不足可能危险，而过度诊断可能代价高昂。
报告我们在以色列一家以急诊室心脏病专家为主的胸痛中心的初步经验。
在一项为期5周的试点研究中，我们检查了124例病因不明的胸痛患者或非高危急性冠状动脉综合征患者的资源利用情况和急诊室诊断。首次评估由急诊室医生进行，随后由胸痛中心团队进行第二次评估。评估基于以下参数：病史和体格检查、系列心电图、血液学、生物化学以及急性冠状动脉综合征的生物标志物、运动负荷试验和/或64层多探测器心脏计算机断层扫描血管造影。记录初始评估和胸痛中心最终评估之间在住院和资源利用决策方面的变化。
所有患者至少进行了两次心肌肌钙蛋白T测量，19例进行了运动负荷试验，9例进行了超声心动图检查，29例进行了心脏多层螺旋CT检查。14例患者被转诊进行早期心脏导管插入术（当天或次日）。在84例住院患者中，71例得出了明确的工作诊断，其中不稳定型心绞痛39例（31%），非ST段抬高型心肌梗死12例（10%）。经过胸痛中心评估后，124例患者中有40例（32%）出院，49例（39%）入住内科，35例（28%）入住心内科。胸痛中心评估和更多资源的投入使得101例最初被急诊室评估确定为住院候选者的患者中有30例（30%）得以出院。此外，最初被急诊室评估为出院候选者的23例患者中有13例（56%）最终住院。急诊室出院患者使用非侵入性检查的比例显著更高（85%对住院患者的38%）（P<0.0001）。出院患者的急诊室平均停留时间往往更长（14.9±8.6小时对12.9±11小时，P=无显著差异）。在30天随访时，胸痛中心评估后从急诊室出院的40例患者中无一例出现不良事件（心肌梗死或死亡）。1例患者因胸痛返回急诊室，重新评估后出院。
我们的初步经验表明，以急诊室心脏病专家为主的胸痛中心改善了对到急诊室就诊的胸痛患者的评估，并在决定急诊室入院/出院之前加强了诊断检查的合理使用。
