Hall Michael E, Miller Chadwick D, Hundley W Gregory
Department of Internal Medicine/Cardiology, Wake Forest University Health Sciences, Winston-Salem, NC, USA.
Curr Treat Options Cardiovasc Med. 2012 Feb;14(1):117-25. doi: 10.1007/s11936-011-0156-3.
Although clear algorithms for diagnosis and treatment of patients with chest pain at low or high risk for an acute coronary syndrome (ACS) exist, they are less well delineated for patients presenting with chest pain with an intermediate risk for ACS. In patients presenting acutely or subacutely to emergency departments (EDs) at high risk for ACS, such as those with ST segment elevation on their 12-lead electrocardiogram (ECG), immediate contrast coronary angiography is performed. On the other hand, chest pain observation units (OUs) are recommended for managing those with chest pain at low risk for an ACS event. In this setting, these OUs are associated with lower healthcare resource utilization and improved cost-effectiveness. Cost-effective diagnosis and treatment options are important goals in healthcare delivery systems. The presentation of patients at intermediate risk for ACS represents an emerging source of resource utilization for EDs. These patients often exhibit pre-existing coronary artery disease, may have sustained prior myocardial infarction, and exhibit multiple comorbidities such as diabetes and hypercholesterolemia. Importantly, however, they will not have evidence of ST elevation on their 12-lead ECG nor will they exhibit serum markers (troponin or creatinine kinase elevations) indicative of ACS. As a consequence of existing co-morbidities, their management becomes time-consuming and may require inpatient monitoring, observation, and cardiac stress testing. Cardiovascular magnetic resonance (CMR) is a powerful tool for risk stratification and prognosis determination in patients in need of stress testing at intermediate risk of ACS. For those who present with acute chest pain syndromes, the combination of CMR in an OU setting represents a potentially attractive option for reducing healthcare-related expenditures without compromising patient outcomes. Recent study results from single centers suggest that CMR-OU care may result in fewer unnecessary hospital admissions and invasive procedures in those presenting with intermediate risk ACS. Further research utilizing stress CMR testing from multiple centers in OU settings is needed to determine if this model of care improves efficiency, reduces healthcare costs, and delivers optimum care in individuals presenting to EDs with chest pain at intermediate risk of ACS.
虽然存在针对急性冠状动脉综合征（ACS）低风险或高风险胸痛患者的明确诊断和治疗算法，但对于ACS中等风险胸痛患者的算法描述较少。对于急性或亚急性就诊于急诊科（ED）且ACS高风险的患者，如12导联心电图（ECG）有ST段抬高的患者，需立即进行冠状动脉造影。另一方面，对于ACS事件低风险胸痛患者，建议采用胸痛观察单元（OU）进行管理。在这种情况下，这些观察单元与较低的医疗资源利用和更高的成本效益相关。具有成本效益的诊断和治疗方案是医疗保健系统的重要目标。ACS中等风险患者的就诊是急诊科资源利用的一个新来源。这些患者常患有冠状动脉疾病，可能曾发生过心肌梗死，且存在多种合并症，如糖尿病和高胆固醇血症。然而，重要的是，他们的12导联ECG上不会有ST段抬高的证据，也不会出现提示ACS的血清标志物（肌钙蛋白或肌酸激酶升高）。由于存在合并症，对他们的管理耗时且可能需要住院监测、观察和心脏负荷试验。心血管磁共振（CMR）是对ACS中等风险且需要进行负荷试验的患者进行风险分层和预后判定时的有力工具。对于那些出现急性胸痛综合征的患者，在观察单元环境中结合CMR是在不影响患者预后的情况下降低医疗相关费用的一个潜在有吸引力的选择。单中心近期的研究结果表明，CMR观察单元护理可能会减少ACS中等风险患者不必要的住院和侵入性操作。需要在观察单元环境中利用多个中心的负荷CMR试验进行进一步研究，以确定这种护理模式是否能提高效率、降低医疗成本，并为就诊于急诊科的ACS中等风险胸痛患者提供最佳护理。
