Division of Cardiology, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania.
Department of Public Health Sciences, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania.
JAMA Intern Med. 2015 Mar;175(3):428-36. doi: 10.1001/jamainternmed.2014.7657.
Patients presenting to the emergency department (ED) with chest pain whose evaluation for ischemia demonstrates no abnormalities receive further functional or anatomical studies for coronary artery disease; however, comparative evidence for the various strategies is lacking and multiple testing options exist.
To compare chest pain evaluation pathways based on their association with downstream testing, interventions, and outcomes for patients in EDs.
DESIGN, SETTING, AND PARTICIPANTS: Retrospective analysis of health insurance claims data for a national sample of privately insured patients from January 1 to December 31, 2011. Individuals with a primary or secondary diagnosis of chest pain in the ED were selected and classified into 1 of 5 testing strategies: no noninvasive testing, exercise electrocardiography, stress echocardiography, myocardial perfusion scintigraphy, or coronary computed tomography angiography.
The proportion of patients in each group who received a cardiac catheterization, coronary revascularization procedure, or future noninvasive test as well as those who were hospitalized for an acute myocardial infarction (MI) during 7 and 190 days of follow-up.
In 2011, there were 693 212 ED visits with a primary or secondary diagnosis of chest pain, accounting for 9.2% of all ED encounters. After application of the inclusion and exclusion criteria, 421 774 patients were included in the final analysis; 293 788 individuals did not receive an initial noninvasive test and 127 986 did, representing 1.7% of all ED encounters. Overall, the percentage of patients hospitalized with an MI was very low during both 7 and 190 days of follow-up (0.11% and 0.33%, respectively). Patients who did not undergo initial noninvasive testing were no more likely to experience an MI than were those who did receive testing. Compared with no testing, exercise electrocardiography, myocardial perfusion scintigraphy, and coronary computed tomography angiography were associated with significantly higher odds of cardiac catheterization and revascularization procedures without a concomitant improvement in the odds of experiencing an MI.
Patients with chest pain evaluated in the ED who do not have an MI are at very low risk of experiencing an MI during short- and longer-term follow-up in a cohort of privately insured patients. This low risk does not appear to be affected by the initial testing strategy. Deferral of early noninvasive testing appears to be reasonable.
在急诊科（ED）就诊的胸痛患者，其缺血评估未见异常，进一步进行冠状动脉疾病的功能或解剖学研究；然而，缺乏对各种策略的比较证据，并且有多种测试选择。
比较基于 ED 患者下游测试、干预和结局的胸痛评估途径。
设计、设置和参与者：回顾性分析 2011 年 1 月 1 日至 12 月 31 日期间全国私人保险患者的健康保险索赔数据。选择有 ED 中主要或次要胸痛诊断的个体，并将其分为 5 种测试策略之一：无非侵入性测试、运动心电图、应激超声心动图、心肌灌注闪烁成像或冠状动脉计算机断层血管造影。
每个组中接受心导管插入术、冠状动脉血运重建术或未来非侵入性检查的患者比例，以及在 7 天和 190 天随访期间因急性心肌梗死（MI）住院的患者比例。
2011 年，ED 就诊中有 693212 例胸痛患者，占 ED 就诊总数的 9.2%。在应用纳入和排除标准后，最终分析纳入 421774 例患者；293788 例患者未接受初始非侵入性检查，占所有 ED 就诊的 1.7%。总体而言，在 7 天和 190 天的随访期间，因 MI 住院的患者比例非常低（分别为 0.11%和 0.33%）。与未接受初始非侵入性检查的患者相比，接受检查的患者发生 MI 的可能性并无显著增加。与不进行任何检查相比，运动心电图、心肌灌注闪烁成像和冠状动脉计算机断层血管造影与接受心导管插入术和血运重建术的几率显著增加相关，而 MI 发生几率并未随之改善。
在接受 ED 评估的胸痛患者中，未发生 MI 的患者在私人保险患者队列的短期和长期随访中发生 MI 的风险非常低。这种低风险似乎不受初始测试策略的影响。早期非侵入性检查的延迟似乎是合理的。
