Department of Emergency Medicine, Mount Sinai School of Medicine, One Gustave L. Levy Place, PO Box 1149, New York, NY 10029, USA.
JAMA Intern Med. 2013 Jun 24;173(12):1128-33. doi: 10.1001/jamainternmed.2013.850.
The American Heart Association recommends routine provocative cardiac testing in accelerated diagnostic protocols for coronary ischemia. The diagnostic and therapeutic yield of this approach are unknown.
To assess the yield of routine provocative cardiac testing in an emergency department-based chest pain unit.
We examined a prospectively collected database of patients evaluated for possible acute coronary syndrome between March 4, 2004, and May 15, 2010, in the emergency department-based chest pain unit of an urban academic tertiary care center.
Patients with signs or symptoms of possible acute coronary syndrome and without an ischemic electrocardiography result or a positive biomarker were enrolled in the database.
All patients were evaluated by exercise stress testing or myocardial perfusion imaging.
Demographic and clinical features, results of routine provocative cardiac testing and angiography, and therapeutic interventions were recorded. Diagnostic yield (true-positive rate) was calculated, and the potential therapeutic yield of invasive therapy was assessed through blinded, structured medical record review using American Heart Association designations (class I, IIa, IIb, or lower) for the potential benefit from percutaneous intervention.
In total, 4181 patients were enrolled in the study. Chest pain was initially reported in 93.5%, most (73.2%) were at intermediate risk for coronary artery disease, and 37.6% were male. Routine provocative cardiac testing was positive for coronary ischemia in 470 (11.2%), of whom 123 underwent coronary angiography. Obstructive disease was confirmed in 63 of 123 (51.2% true positive), and 28 (0.7% overall) had findings consistent with the potential benefit from revascularization (American Heart Association class I or IIa).
In an emergency department-based chest pain unit, routine provocative cardiac testing generated a small therapeutic yield, new diagnoses of coronary artery disease were uncommon, and false-positive results were common.
美国心脏协会建议在加速诊断方案中对冠状动脉缺血进行常规激发性心脏检查。这种方法的诊断和治疗效果尚不清楚。
评估急诊科胸痛单元中常规激发性心脏检查的效果。
我们检查了 2004 年 3 月 4 日至 2010 年 5 月 15 日期间在城市三级学术医疗中心急诊科胸痛单元接受可能急性冠状动脉综合征评估的患者前瞻性收集的数据库。
有急性冠状动脉综合征的症状或体征，且无缺血性心电图结果或阳性生物标志物的患者被纳入数据库。
所有患者均接受运动应激试验或心肌灌注成像检查。
记录患者的人口统计学和临床特征、常规激发性心脏检查和血管造影的结果以及治疗干预措施。计算诊断效果（真阳性率），并通过盲法、结构病历回顾，使用美国心脏协会的设计方案（I 类、IIa 类、IIb 类或更低类）评估血管内治疗的潜在治疗效果。
共纳入 4181 例患者。93.5%的患者最初报告胸痛，73.2%的患者处于中等程度的冠状动脉疾病风险，37.6%的患者为男性。常规激发性心脏检查对冠状动脉缺血呈阳性反应的患者有 470 例（11.2%），其中 123 例行冠状动脉造影术。123 例中，有 63 例（51.2%为真阳性）证实有阻塞性疾病，28 例（总体为 0.7%）有明确的血管重建获益（I 类或 IIa 类）。
在急诊科胸痛单元中，常规激发性心脏检查的治疗效果较小，新诊断的冠状动脉疾病并不常见，且假阳性结果常见。
