Yiadom Maame Yaa A B, Liu Xulei, McWade Conor M, Liu Dandan, Storrow Alan B
Department of Emergency Medicine, Vanderbilt University, Nashville, TN.
Department of Biostatistics, Vanderbilt University, Nashville, TN.
Acad Emerg Med. 2017 Jun;24(6):701-709. doi: 10.1111/acem.13184. Epub 2017 May 8.
In the absence of the existing acute coronary syndrome (ACS) guidelines directing the clinical practice implementation of emergency department (ED) screening and diagnosis, there is variable screening and diagnostic clinical practice across ED facilities. This practice diversity may be warranted. Understanding the variability may identify opportunities for more consistent practice.
This is a cross-sectional clinical practice epidemiology study with the ED as the unit of analysis characterizing variability in the ACS evaluation across 62 diverse EDs. We explored three domains of screening and diagnostic practice: 1) variability in criteria used by EDs to identify patients for an early electrocardiogram (ECG) to diagnose ST-elevation myocardial infarction (STEMI), 2) nonuniform troponin biomarker and formalized pre-troponin risk stratification use for the diagnosis of non-ST-elevation myocardial infarction (NSTEMI), and 3) variation in the use of noninvasive testing (NIVT) to identify obstructive coronary artery disease or detect inducible ischemia.
We found that 85% of EDs utilize a formal triage protocol to screen patients for an early ECG to diagnose STEMI. Of these, 17% use chest pain as the sole criteria. For the diagnosis of NSTEMI, 58% use intervals ≥4 hours for a second troponin and 34% routinely risk stratify before troponin testing. For the diagnosis of noninfarction ischemia, the median percentage of patients who have NIVT performed during their ED visit is 5%. The median percentage of patients referred for NIVT in hospital (observation or admission) is 61%. Coronary CT angiography is used in 66% of EDs. Exercise treadmill testing is the most frequently reported first-line NIVT (42%).
Our results suggest highly variable ACS screening and clinical practice.
在缺乏指导急诊科（ED）筛查和诊断临床实践实施的现有急性冠状动脉综合征（ACS）指南的情况下，各急诊科设施的筛查和诊断临床实践存在差异。这种实践差异可能是有必要的。了解这种变异性可能会发现实现更一致实践的机会。
这是一项横断面临床实践流行病学研究，以急诊科为分析单位，描述了62个不同急诊科在ACS评估中的变异性。我们探讨了筛查和诊断实践的三个领域：1）急诊科用于识别患者进行早期心电图（ECG）以诊断ST段抬高型心肌梗死（STEMI）的标准的变异性，2）用于诊断非ST段抬高型心肌梗死（NSTEMI）的肌钙蛋白生物标志物和正式的肌钙蛋白前风险分层使用不一致，3）用于识别阻塞性冠状动脉疾病或检测诱发性缺血的无创检测（NIVT）使用的变异性。
我们发现85% 的急诊科采用正式的分诊方案来筛查患者进行早期心电图以诊断STEMI。其中，17% 仅以胸痛作为标准。对于NSTEMI的诊断，58% 使用第二次肌钙蛋白检测间隔≥4小时，34% 在肌钙蛋白检测前常规进行风险分层。对于非梗死性缺血的诊断，在急诊科就诊期间接受NIVT检查的患者中位数百分比为5%。在医院（观察或住院）被转诊进行NIVT检查的患者中位数百分比为61%。66% 的急诊科使用冠状动脉CT血管造影。运动平板试验是最常报告的一线NIVT（42%）。
我们的结果表明ACS筛查和临床实践存在高度变异性。
