Kurz Michael Christopher, Babcock Christine, Sinha Shashank, Tupesis Janis P, Allegretti John
Department of Emergency Medicine, Virginia Commonwealth University Medical Center, Richmond, VA 23298-0401, USA.
Ann Emerg Med. 2007 Nov;50(5):527-34. doi: 10.1016/j.annemergmed.2007.03.018. Epub 2007 Jun 20.
We seek to evaluate how accurately the emergency physician initiates percutaneous coronary intervention for patients presenting to the emergency department (ED) with ST-segment-elevation myocardial infarction (STEMI) and the impact of emergency physician-initiated percutaneous coronary intervention on mean door-to-balloon time.
We conducted a before-and-after cohort study of consecutive STEMI patients presenting to a 608-bed tertiary care hospital during a 32-month period. During the first 19 months, percutaneous coronary intervention was available only by consultation with an on-call interventionist. In the subsequent 13 months, percutaneous coronary intervention was initiated by the emergency physician independent of cardiology consultation. All patients presenting during the study period with an appropriate clinical history and characteristic ECG findings of STEMI were eligible. Patients with greater than 12 hours of symptoms, contraindications to percutaneous coronary intervention, a valid do-not-resuscitate order, who died before percutaneous coronary intervention was attempted, who initially refused, or whose door-to-balloon time was greater than 6 hours were excluded. The accuracy of emergency physician identification of STEMI was confirmed by an independent cardiologist. All hospital medical records with a discharge diagnosis of acute myocardial infarction (International Classification of Diseases, Ninth Revision code 410.xx) were reviewed to confirm that no STEMI patients went unidentified. A t test was used to compare mean door-to-balloon time in each cohort.
A total of 172 patients were enrolled in this investigation, 95 STEMI patients in the initial 19-month period and 77 patients in the subsequent 13 months, when percutaneous coronary intervention was initiated solely at the discretion of the emergency physician. Percutaneous coronary intervention was inappropriately initiated by the emergency physician only once, and no ED patients with STEMI were overlooked, resulting in 100% sensitivity (95% confidence interval [CI] 97.3% to 100%) and 99.6% specificity (95% CI 97.7% to 99.9%). Mean door-to-balloon time in the emergency physician-initiated percutaneous coronary intervention cohort improved by 40 minutes (95% CI 26 to 54 minutes) from 131 to 91 minutes.
The emergency physician is able to accurately initiate percutaneous coronary intervention for ED patients presenting with STEMI independent of cardiology consultation. Emergency physician-initiated percutaneous coronary intervention significantly reduces mean door-to-balloon time for these patients.
我们旨在评估急诊医生对因ST段抬高型心肌梗死（STEMI）就诊于急诊科（ED）的患者进行经皮冠状动脉介入治疗的准确性，以及急诊医生发起的经皮冠状动脉介入治疗对平均门球时间的影响。
我们对一家拥有608张床位的三级医疗中心在32个月期间连续就诊的STEMI患者进行了一项前后队列研究。在最初的19个月里，只有通过联系值班介入医生会诊才能进行经皮冠状动脉介入治疗。在随后的13个月里，经皮冠状动脉介入治疗由急诊医生独立发起，无需心脏病学会诊。所有在研究期间就诊且有适当临床病史和STEMI特征性心电图表现的患者均符合条件。症状持续超过12小时、有经皮冠状动脉介入治疗禁忌症、有有效的不要复苏医嘱、在尝试经皮冠状动脉介入治疗前死亡、最初拒绝治疗或门球时间超过6小时的患者被排除。急诊医生对STEMI的识别准确性由一名独立的心脏病专家确认。所有出院诊断为急性心肌梗死（国际疾病分类第九版代码410.xx）的医院病历均经过审查，以确认没有STEMI患者未被识别。使用t检验比较每个队列中的平均门球时间。
本研究共纳入172例患者，最初19个月期间有95例STEMI患者，随后13个月有77例患者，此时经皮冠状动脉介入治疗完全由急诊医生自行决定发起。急诊医生仅不恰当地发起过一次经皮冠状动脉介入治疗，且没有ED的STEMI患者被漏诊，灵敏度为100%（95%置信区间[CI]97.3%至100%），特异度为99.6%（95%CI97.7%至99.9%）。急诊医生发起的经皮冠状动脉介入治疗队列中的平均门球时间从131分钟缩短至91分钟，缩短了40分钟（95%CI26至54分钟）。
急诊医生能够在不依赖心脏病学会诊的情况下，准确地为就诊于ED的STEMI患者发起经皮冠状动脉介入治疗。急诊医生发起的经皮冠状动脉介入治疗显著缩短了这些患者的平均门球时间。
