医生的酌情决定权是安全的，并且可能会降低急诊科胸痛单元患者的压力测试使用率。

Physician discretion is safe and may lower stress test utilization in emergency department chest pain unit patients.

作者信息

Napoli Anthony M, Arrighi James A, Siket Matthew S, Gibbs Frantz J

机构信息

Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Rhode Island Hospital, Providence, RI 02903, USA.

出版信息

Crit Pathw Cardiol. 2012 Mar;11(1):26-31. doi: 10.1097/HPC.0b013e3182457bee.

DOI:10.1097/HPC.0b013e3182457bee

PMID:22337218

Abstract

INTRODUCTION

Chest pain unit (CPU) observation with defined stress utilization protocols is a common management option for low-risk emergency department patients. We sought to evaluate the safety of a joint emergency medicine and cardiology staffed CPU.

METHODS

Prospective observational trial of consecutive patients admitted to an emergency department CPU was conducted. A standard 6-hour observation protocol was followed by cardiology consultation and stress utilization largely at their discretion. Included patients were at low/intermediate risk by the American Heart Association, had nondiagnostic electrocardiograms, and a normal initial troponin. Excluded patients were those with an acute comorbidity, age >75, and a history of coronary artery disease, or had a coexistent problem restricting 24-hour observation. Primary outcome was 30-day major adverse cardiovascular events-defined as death, nonfatal acute myocardial infarction, revascularization, or out-of-hospital cardiac arrest.

RESULTS

A total of 1063 patients were enrolled over 8 months. The mean age of the patients was 52.8 ± 11.8 years, and 51% (95% confidence interval [CI], 48-54) were female. The mean thrombolysis in myocardial infarction and Diamond & Forrester scores were 0.6% (95% CI, 0.51-0.62) and 33% (95% CI, 31-35), respectively. In all, 51% (95% CI, 48-54) received stress testing (52% nuclear stress, 39% stress echocardiogram, 5% exercise, 4% other). In all, 0.9% patients (n = 10, 95% CI, 0.4-1.5) were diagnosed with a non-ST elevation myocardial infarction and 2.2% (n = 23, 95% CI, 1.3-3) with acute coronary syndrome. There was 1 (95% CI, 0%-0.3%) case of a 30-day major adverse cardiovascular events. The 51% stress test utilization rate was less than the range reported in previous CPU studies (P < 0.05).

CONCLUSIONS

Joint emergency medicine and cardiology management of patients within a CPU protocol is safe, efficacious, and may safely reduce stress testing rates.

摘要

引言

采用明确的应激利用方案对胸痛单元（CPU）进行观察，是低风险急诊科患者常见的管理选择。我们旨在评估由急诊医学和心脏病学联合配备人员的CPU的安全性。

方法

对连续入住急诊科CPU的患者进行前瞻性观察性试验。遵循标准的6小时观察方案，之后主要由心脏病学专家自行决定是否进行会诊和应激利用。纳入的患者根据美国心脏协会标准处于低/中度风险，心电图无诊断意义，肌钙蛋白初始值正常。排除的患者包括患有急性合并症、年龄>75岁、有冠状动脉疾病史，或存在限制24小时观察的并存问题的患者。主要结局是30天主要不良心血管事件，定义为死亡、非致命性急性心肌梗死、血运重建或院外心脏骤停。

结果

在8个月内共纳入1063例患者。患者的平均年龄为52.8±11.8岁，51%（95%置信区间[CI]，48 - 54）为女性。平均心肌梗死溶栓和Diamond & Forrester评分分别为0.6%（95% CI，0.51 - 0.62）和33%（95% CI，31 - 35）。总体而言，51%（95% CI，48 - 54）的患者接受了应激测试（52%为核素应激，39%为应激超声心动图，5%为运动，4%为其他）。总体而言，0.9%的患者（n = 10，95% CI，0.4 - 1.5）被诊断为非ST段抬高型心肌梗死，2.2%（n = 23，95% CI，1.3 - 3）被诊断为急性冠状动脉综合征。有1例（95% CI，0% - 0.3%）发生30天主要不良心血管事件。51%的应激测试利用率低于以往CPU研究报告的范围（P < 0.05）。