Sun Benjamin C, Laurie Amber, Fu Rongwei, Ferencik Maros, Shapiro Michael, Lindsell Christopher J, Diercks Deborah, Hoekstra James W, Hollander Judd E, Kirk J Douglas, Peacock W Frank, Gibler W Brian, Anantharaman Venkataraman, Pollack Charles V
From the *Department of Emergency Medicine, †Division of Cardiovascular Medicine, Oregon Health and Science University, Portland, OR; ‡Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH; §Department of Emergency Medicine, University of Texas Southwestern, Dallas, TX; ¶Department of Emergency Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC; ‖Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA; **Department of Emergency Medicine, University of California Davis Medical Center, Sacramento, CA; ††Department of Emergency Medicine, Baylor College of Medicine, Houston, TX; and ‡‡Department of Emergency Medicine, Singapore General Hospital, Singapore.
Crit Pathw Cardiol. 2016 Jun;15(2):60-8. doi: 10.1097/HPC.0000000000000068.
Professional society guidelines suggest early stress testing (within 72 hours) after an emergency department (ED) evaluation for suspected acute coronary syndrome (ACS). However, there is increasing concern that current practice results in over-testing without evidence of benefit. We test the hypothesis that early stress testing improves outcomes.
We analyzed prospectively collected data from 9 EDs on patients with suspected ACS, 1999-2001. We excluded patients with an ED diagnosis of ACS. The primary outcome was 30-day major adverse cardiac events (MACEs), including all-cause death, acute myocardial infarction, and revascularization. We used the HEART score to determine pretest ACS risk (low, intermediate, and high). To mitigate potential confounding, patients with and without early stress testing were matched within pretest risk strata in a 1:2 ratio using propensity scores.
Of 7127 potentially eligible patients, 895 (13%) received early stress testing. The analytic cohort included 895 patients with early stress testing matched to 1790 without early stress testing. The overall 30-day MACE rate in both the source and analytic population was 3%. There were no baseline imbalances after propensity score matching (P > 0.1 for more than 30 variables). There was no association between early stress testing and 30-day MACE [odds ratio, 1.0; 95% confidence interval (CI), 0.6-1.7]. There was no effect modification by pretest risk (low: odds ratio, 1.0; 95% CI, 0.2-3.7; intermediate: 1.2; 95% CI, 0.6-2.6; high: 0.4; 95% CI, 0.1-1.6).
Early stress testing is not associated with reduced MACE in patients evaluated for suspected ACS. Early stress testing may have limited value in populations with low MACE rate.
专业协会指南建议，在急诊科（ED）对疑似急性冠状动脉综合征（ACS）进行评估后尽早进行负荷试验（72小时内）。然而，人们越来越担心目前的做法导致过度检查且无获益证据。我们检验早期负荷试验可改善预后这一假设。
我们分析了1999年至2001年从9个急诊科前瞻性收集的疑似ACS患者的数据。我们排除了急诊科诊断为ACS的患者。主要结局是30天主要不良心脏事件（MACE），包括全因死亡、急性心肌梗死和血运重建。我们使用HEART评分来确定负荷试验前ACS风险（低、中、高）。为减轻潜在的混杂因素，使用倾向评分按1:2的比例在负荷试验前风险分层内对进行和未进行早期负荷试验的患者进行匹配。
在7127名可能符合条件的患者中，895名（13%）接受了早期负荷试验。分析队列包括895名进行早期负荷试验的患者与1790名未进行早期负荷试验的患者相匹配。来源人群和分析人群中30天MACE的总体发生率均为3%。倾向评分匹配后无基线不平衡（超过30个变量P>0.1）。早期负荷试验与30天MACE之间无关联[比值比，1.0；95%置信区间（CI），0.6 - 1.7]。负荷试验前风险无效应修正（低：比值比，1.0；95% CI，0.2 - 3.7；中：1.2；95% CI，0.6 - 2.6；高：0.4；95% CI，0.1 - 1.6）。
对于疑似ACS的患者，早期负荷试验与降低MACE无关。早期负荷试验在MACE发生率低的人群中可能价值有限。
