Milano Peter, Carden Donna L, Jackman Kelly M, Rongkavilit Arada, Groves Kevin, Tyndall Joseph, Moll Joel
Department of Emergency Medicine, University of Florida College of Medicine, Gainesville.
Crit Pathw Cardiol. 2011 Mar;10(1):35-40. doi: 10.1097/HPC.0b013e31820fd9bd.
Recent evidence suggests that stress testing prior to emergency department (ED) release in low-risk chest pain patients identifies those who can be safely discharged home. When immediate stress testing is not feasible, rapid outpatient stress testing has been recommended. The objective of this study was to determine compliance rate and incidence of adverse cardiac events in patients presenting to the ED with low-risk chest pain referred for outpatient stress testing. Retrospective chart and social security death index review were conducted in 448 consecutive chest pain patients who presented to a university hospital and level I trauma center between April 30 and December 31, 2007. Patients were evaluated with an accelerated chest pain protocol defined as a 4-hour ED rule out and referral for outpatient stress testing within 72 hours of ED release. Only patients without known cardiac disease, a thrombolysis in myocardial infarction risk score ≤2, negative serial ECGs and cardiac biomarkers, and benign ED course were eligible for the protocol. Primary outcome measures included compliance with outpatient stress testing and documented 30-day incidence of adverse cardiac events following ED release. The social security death index was queried to determine 12-month incidence of all-cause mortality in enrolled patients. Logistic regression analysis of characteristics associated with outpatient stress test compliance was determined and incidence of adverse cardiac events in those who were and were not compliant with outpatient stress testing was compared. Significance was set at P < 0.05. A total of 188 patients (42%) completed outpatient stress testing, but only 27 (6%) completed testing within 72 hours of ED discharge. Compliance was correlated with insurance and race, but not patient age, gender, or thrombolysis in myocardial infarction risk score. No significant differences in adverse cardiac events were documented in patients who did and did not comply with outpatient stress testing. Compliance with outpatient stress testing is poor in low-risk chest pain patients following ED release. Despite poor compliance, the documented incidence of adverse cardiac events in this low-risk cohort was lower than that reported in patients with negative provocative testing prior to ED release.
近期证据表明，在低风险胸痛患者从急诊科（ED）出院前进行负荷试验，可识别出那些能够安全出院回家的患者。当即时负荷试验不可行时，推荐进行快速门诊负荷试验。本研究的目的是确定因低风险胸痛到急诊科就诊并被转诊进行门诊负荷试验的患者的依从率和不良心脏事件发生率。对2007年4月30日至12月31日期间到一家大学医院和一级创伤中心就诊的448例连续胸痛患者进行了回顾性病历和社会保障死亡指数审查。患者按照加速胸痛方案进行评估，该方案定义为在急诊科4小时排除，并在从急诊科出院后72小时内转诊进行门诊负荷试验。只有无已知心脏病、心肌梗死溶栓风险评分≤2、系列心电图和心脏生物标志物阴性且急诊科病程良性的患者符合该方案。主要结局指标包括对门诊负荷试验的依从性以及记录从急诊科出院后30天内不良心脏事件的发生率。查询社会保障死亡指数以确定入组患者全因死亡率的12个月发生率。确定与门诊负荷试验依从性相关特征的逻辑回归分析，并比较依从和不依从门诊负荷试验患者中不良心脏事件的发生率。显著性设定为P<0.05。共有188例患者（42%）完成了门诊负荷试验，但只有27例（6%）在从急诊科出院后72小时内完成了试验。依从性与保险和种族相关，但与患者年龄、性别或心肌梗死溶栓风险评分无关。在依从和不依从门诊负荷试验的患者中，不良心脏事件无显著差异。低风险胸痛患者从急诊科出院后对门诊负荷试验的依从性较差。尽管依从性差，但该低风险队列中记录的不良心脏事件发生率低于在从急诊科出院前激发试验阴性的患者中报告的发生率。
