Guirgis Faheem W, Gray-Eurom Kelly, Mayfield Teri L, Imbt David M, Kalynych Colleen J, Kraemer Dale F, Godwin Steven A
University of Florida, Department of Emergency Medicine, Jacksonville, Florida.
University of Florida College of Medicine, Jacksonville; Center for Health Equity and Quality Research.
West J Emerg Med. 2014 Mar;15(2):180-3. doi: 10.5811/westjem.2013.11.19232.
In 2007 there were 64,000 visits to the emergency department (ED) for possible myocardial infarction (MI) related to cocaine use. Prior studies have demonstrated that low- to intermediate-risk patients with cocaine-associated chest pain can be safely discharged after 9-12 hours of observation. The goal of this study was to determine the safety of an 8-hour protocol for ruling out MI in patients who presented with cocaine-associated chest pain.
We conducted a retrospective review of patients treated with an 8-hour cocaine chest pain protocol between May 1, 2011 and November 30, 2012 who were sent to the clinical decision unit (CDU) for observation. The protocol included serial cardiac biomarker testing with Troponin-T, CK-MB (including delta CK-MB), and total CK at 0, 2, 4, and 8 hours after presentation with cardiac monitoring for the observation period. Patients were followed up for adverse cardiac events or death within 30 days of discharge.
There were 111 admissions to the CDU for cocaine chest pain during the study period. One patient had a delta CK-MB of 1.6 ng/ml, but had negative Troponin-T at all time points. No patient had a positive Troponin-T or CK-MB at 0, 2, 4 or 8 hours, and there were no MIs or deaths within 30 days of discharge. Most patients were discharged home (103) and there were 8 inpatient admissions from the CDU. Of the admitted patients, 2 had additional stress tests that were negative, 1 had additional cardiac biomarkers that were negative, and all 8 patients were discharged home. The estimated risk of missing MI using our protocol is, with 99% confidence, less than 5.1% and with 95% confidence, less than 3.6% (99% CI, 0-5.1%; 95% CI, 0-3.6%).
Application of an abbreviated cardiac enzyme protocol resulted in the safe and rapid discharge of patients presenting to the ED with cocaine-associated chest pain.
2007年，有64000人次因可能与使用可卡因相关的心肌梗死（MI）前往急诊科（ED）就诊。先前的研究表明，伴有可卡因相关性胸痛的低至中度风险患者在观察9 - 12小时后可安全出院。本研究的目的是确定对伴有可卡因相关性胸痛的患者采用8小时方案排除MI的安全性。
我们对2011年5月1日至2012年11月30日期间按照8小时可卡因胸痛方案治疗并被送往临床决策单元（CDU）进行观察的患者进行了回顾性研究。该方案包括在就诊后0、2、4和8小时进行肌钙蛋白 - T、肌酸激酶同工酶MB（包括肌酸激酶同工酶MB变化值）和总肌酸激酶的系列心脏生物标志物检测，并在观察期内进行心脏监测。对患者出院后30天内的不良心脏事件或死亡情况进行随访。
在研究期间，有111例因可卡因胸痛入住CDU。1例患者的肌酸激酶同工酶MB变化值为1.6 ng/ml，但所有时间点的肌钙蛋白 - T均为阴性。在0、2、4或8小时时，没有患者的肌钙蛋白 - T或肌酸激酶同工酶MB呈阳性，出院后30天内也没有发生心肌梗死或死亡。大多数患者（103例）出院回家，CDU有8例住院患者。在入院患者中，2例进行了额外的应激试验，结果为阴性，1例进行了额外的心脏生物标志物检测，结果为阴性，所有8例患者均出院回家。使用我们的方案漏诊心肌梗死的估计风险，在99%置信度下小于5.1%，在95%置信度下小于3.6%（99%可信区间，0 - 5.1%；95%可信区间，0 - 3.6%）。
应用简化的心脏酶方案可使因可卡因相关性胸痛就诊于急诊科的患者安全、快速出院。
