Madsen Troy E, Stewart Matthew, Smyres Cameron, Beal Angus, Hamilton David, Vlasic Kajsa, Oates Alexis
From the University of Utah, Salt Lake City, Utah.
Crit Pathw Cardiol. 2015 Dec;14(4):146-9. doi: 10.1097/HPC.0000000000000054.
Previous studies have suggested that patients with an indeterminate troponin I (TnI) in the emergency department (ED) are significantly more likely to be diagnosed with acute myocardial infarction (MI). The role of the ED observation unit (EDOU) in the evaluation of these patients is unclear.
We sought to determine the risk of MI and revascularization in chest pain patients with an indeterminate TnI in the ED, who were placed in an EDOU.
We performed a prospective evaluation with 30-day follow-up for all chest pain patients placed in the University of Utah EDOU between June 1, 2009 and May 31, 2012. The EDOU excludes patients with a positive TnI, significant electrocardiogram changes, or active chest pain; however, the EDOU is utilized for further evaluation of patients who have an initial indeterminate TnI (0.06 ng/mL-0.49 ng/mL) with serial TnI measurements, cardiology consult, and potential provocative testing. We identified all patients who had an indeterminate TnI on initial testing in the ED. Primary outcomes were MI, revascularization with cardiac stent or coronary artery bypass graft, and death.
We evaluated 1276 chest pain patients in the EDOU over the 3-year study period (average age: 54.1 years, 54% female). Fifty-eight patients (4.5%) had an initial indeterminate TnI. There were no deaths or adverse outcomes in the EDOU among those with an indeterminate TnI, and none of these patients developed a positive TnI during their hospital stay or 30-day follow-up. Patients with an indeterminate TnI had a higher rate of inpatient admission from the EDOU (24.1% vs. 10.3%; P=0.001). Among those with an indeterminate TnI, 8.6% underwent revascularization, while the rate of revascularization or MI was 2.9% among those who did not have an initial indeterminate TnI (P=0.032).
Patients evaluated in our EDOU for chest pain with an initial indeterminate TnI did not develop subsequent MI. However, these patients had an increased rate of revascularization and inpatient admission compared with controls. While our experience suggests that patients with an indeterminate TnI may be safely evaluated in an observation setting, EDOUs which treat only low-risk chest pain patients may wish to recommend inpatient admission for this patient group.
既往研究表明，急诊科（ED）肌钙蛋白I（TnI）结果不确定的患者被诊断为急性心肌梗死（MI）的可能性显著更高。ED观察单元（EDOU）在评估这些患者中的作用尚不清楚。
我们试图确定在ED中TnI结果不确定且被收入EDOU的胸痛患者发生MI和血运重建的风险。
我们对2009年6月1日至2012年5月31日期间收入犹他大学EDOU的所有胸痛患者进行了为期30天的前瞻性评估。EDOU排除TnI阳性、心电图有显著变化或有活动性胸痛的患者；然而，EDOU用于对初始TnI结果不确定（0.06 ng/mL - 0.49 ng/mL）的患者进行进一步评估，包括连续检测TnI、心内科会诊以及可能的激发试验。我们确定了所有在ED初始检测时TnI结果不确定的患者。主要结局为MI、接受心脏支架或冠状动脉旁路移植术的血运重建以及死亡。
在为期3年的研究期间，我们在EDOU评估了1276例胸痛患者（平均年龄：54.1岁，54%为女性）。58例患者（4.5%）初始TnI结果不确定。TnI结果不确定的患者在EDOU期间无死亡或不良结局，且这些患者在住院期间或30天随访中均未出现TnI阳性。TnI结果不确定的患者从EDOU住院的比例更高（24.1%对10.3%；P = 0.001）。在TnI结果不确定的患者中，8.6%接受了血运重建，而初始TnI结果无不确定的患者中血运重建或MI的比例为2.9%（P = 0.032）。
在我们的EDOU中接受评估的初始TnI结果不确定的胸痛患者未发生后续MI。然而，与对照组相比，这些患者的血运重建率和住院率有所增加。虽然我们的经验表明，TnI结果不确定的患者可以在观察环境中安全地进行评估，但仅治疗低风险胸痛患者的EDOU可能希望建议将该患者群体收入住院。
