Scheuermeyer Frank Xavier, Wong Hubert, Yu Eugenia, Boychuk Barb, Innes Grant, Grafstein Eric, Gin Kenneth, Christenson Jim
CJEM. 2014 Mar;16(2):106-19. doi: 10.2310/8000.2013.130938.
Current guidelines emphasize that emergency department (ED) patients at low risk for potential ischemic chest pain cannot be discharged without extensive investigations or hospitalization to minimize the risk of missing acute coronary syndrome (ACS). We sought to derive and validate a prediction rule that permitted 20 to 30% of ED patients without ACS safely to be discharged within 2 hours without further provocative cardiac testing.
This prospective cohort study enrolled 1,669 chest pain patients in two blocks in 2000-2003 (development cohort) and 2006 (validation cohort). The primary outcome was 30-day ACS diagnosis. A recursive partitioning model incorporated reliable and predictive cardiac risk factors, pain characteristics, electrocardiographic findings, and cardiac biomarker results.
In the derivation cohort, 165 of 763 patients (21.6%) had a 30-day ACS diagnosis. The derived prediction rule was 100.0% sensitive and 18.6% specific. In the validation cohort, 119 of 906 patients (13.1%) had ACS, and the prediction rule was 99.2% sensitive (95% CI 95.4-100.0) and 23.4% specific (95% CI 20.6-26.5). Patients have a very low ACS risk if arrival and 2-hour troponin levels are normal, the initial electrocardiogram is nonischemic, there is no history of ACS or nitrate use, age is < 50 years, and defined pain characteristics are met. The validation of the rule was limited by the lack of consistency in data capture, incomplete follow-up, and lack of evaluation of the accuracy, comfort, and clinical sensibility of this clinical decision rule.
The Vancouver Chest Pain Rule may identify a cohort of ED chest pain patients who can be safely discharged within 2 hours without provocative cardiac testing. Further validation across other centres with consistent application and comprehensive and uniform follow-up of all eligible and enrolled patients, in addition to measuring and reporting the accuracy of and comfort level with applying the rule and the clinical sensibility, should be completed prior to adoption and implementation.
当前指南强调，对于潜在缺血性胸痛低风险的急诊科（ED）患者，若不进行全面检查或住院治疗，就无法出院，以将漏诊急性冠状动脉综合征（ACS）的风险降至最低。我们试图推导并验证一种预测规则，该规则允许20%至30%无ACS的ED患者在2小时内安全出院，无需进一步的激发性心脏检查。
这项前瞻性队列研究在2000 - 2003年分两个阶段纳入了1669例胸痛患者（推导队列），并在2006年纳入了验证队列。主要结局是30天内的ACS诊断。递归划分模型纳入了可靠且具有预测性的心脏危险因素、疼痛特征、心电图表现和心脏生物标志物结果。
在推导队列中，763例患者中有165例（21.6%）在30天内被诊断为ACS。推导的预测规则敏感性为100.0%，特异性为18.6%。在验证队列中，906例患者中有119例（13.1%）患有ACS，预测规则敏感性为99.2%（95%CI 95.4 - 100.0），特异性为23.4%（95%CI 20.6 - 26.5）。如果患者到达时和2小时后的肌钙蛋白水平正常、初始心电图无缺血表现、无ACS或使用硝酸盐的病史、年龄<50岁且符合特定的疼痛特征，则其ACS风险非常低。该规则的验证受到数据采集不一致、随访不完整以及未评估该临床决策规则的准确性、舒适度和临床敏感性的限制。
温哥华胸痛规则可能识别出一组ED胸痛患者，他们可以在2小时内安全出院，无需进行激发性心脏检查。在采用和实施之前，应在其他中心进行进一步验证，包括一致的应用、对所有符合条件并登记的患者进行全面统一的随访，同时测量和报告应用该规则的准确性、舒适度水平以及临床敏感性。
