Department of Emergency Medicine, Division of Emergency Medicine Research, Mayo Clinic College of Medicine, Rochester, MN, USA.
Ann Emerg Med. 2012 Feb;59(2):115-25.e1. doi: 10.1016/j.annemergmed.2011.07.026. Epub 2011 Sep 1.
Evaluation of emergency department (ED) patients with chest pain who are at low risk for acute coronary syndrome is resource intensive and may lead to false-positive test results and unnecessary downstream procedures. We seek to identify patients at low short-term risk for a cardiac event for whom additional ED investigations might be unnecessary.
We prospectively enrolled patients older than 24 years and with a primary complaint of chest pain from 3 academic EDs. Physicians completed standardized data collection forms before diagnostic testing. The primary adjudicated outcome was acute myocardial infarction, revascularization, or death of cardiac or unknown cause within 30 days. We used recursive partitioning to derive the rule and validated the model with 5,000 bootstrap replications.
Of 2,718 patients enrolled, 336 (12%) experienced a cardiac event within 30 days (6% acute myocardial infarction, 10% revascularization, 0.2% death). We developed a rule consisting of the absence of 5 predictors: ischemic ECG changes not known to be old, history of coronary artery disease, pain typical for acute coronary syndrome, initial or 6-hour troponin level greater than the 99th percentile, and age greater than 50 years. Patients aged 40 years or younger required only a single troponin evaluation. The rule was 100% sensitive (95% confidence interval 97.2% to 100.0%) and 20.9% specific (95% confidence interval 16.9% to 24.9%) for a cardiac event within 30 days.
This clinical prediction rule identifies ED chest pain patients at very low risk for a cardiac event who may be suitable for discharge. A prospective multicenter study is needed to validate the rule and determine its effect on practice.
对胸痛且急性冠脉综合征风险较低的急诊科（ED）患者进行评估需要耗费大量资源，并且可能导致假阳性检测结果和不必要的下游检查。我们旨在确定短期发生心脏事件风险较低的患者，对于这些患者，可能无需进行额外的 ED 检查。
我们前瞻性纳入了来自 3 家学术 ED 的年龄大于 24 岁且主诉为胸痛的患者。医生在进行诊断性检查前填写标准化数据采集表。主要的判定结局为 30 天内发生急性心肌梗死、血运重建或心脏性或未知原因死亡。我们使用递归分区法推导出规则，并使用 5000 次 bootstrap 重复对模型进行验证。
在纳入的 2718 例患者中，336 例（12%）在 30 天内发生了心脏事件（6%为急性心肌梗死，10%为血运重建，0.2%为心脏性或未知原因死亡）。我们制定了一条规则，包含 5 个预测指标均为阴性：心电图提示陈旧性而非新发缺血改变、有冠心病病史、胸痛符合急性冠脉综合征表现、初始或 6 小时肌钙蛋白水平大于第 99 百分位数、年龄大于 50 岁。年龄 40 岁或以下的患者仅需进行单次肌钙蛋白检查。该规则对 30 天内心脏事件的敏感性为 100%（95%置信区间为 97.2%至 100.0%），特异性为 20.9%（95%置信区间为 16.9%至 24.9%）。
该临床预测规则确定了胸痛且急性冠脉综合征风险非常低的 ED 患者，这些患者可能适合出院。需要进行前瞻性多中心研究来验证该规则，并确定其对实践的影响。
