Frisoli Tiberio M, Nowak Richard, Evans Kaleigh L, Harrison Michael, Alani Maath, Varghese Saira, Rahman Mehnaz, Noll Samantha, Flannery Katherine R, Michaels Alex, Tabaku Mishel, Jacobsen Gordon, McCord James
From the Heart and Vascular Institute (T.M.F., M.T., J.M.), Department of Emergency Medicine (R.N., M.H., S.N., K.R.F.), Department of Internal Medicine (K.L.E., M.A., S.V., M.R., A.M.), and Biostatistics Division, Department of Public Health Sciences (G.J.), Henry Ford Hospital, Detroit, MI.
Circ Cardiovasc Qual Outcomes. 2017 Oct;10(10). doi: 10.1161/CIRCOUTCOMES.117.003617.
Hospital evaluation of patients with chest pain is common and costly. The HEART score risk stratification tool that merges troponin testing into a clinical risk model for evaluation emergency department patients with possible acute myocardial infarction (AMI) has been shown to effectively identify a substantial low-risk subset of patients possibly safe for early discharge without stress testing, a strategy that could have tremendous healthcare savings implications.
A total of 105 patients evaluated for AMI in the emergency departments of 2 teaching hospitals in the Henry Ford Health System (Detroit and West Bloomfield, MI), between February 2014 and May 2015, with a modified HEART score ≤3 (which includes cardiac troponin I <0.04 ng/mL at 0 and 3 hours) were randomized to immediate discharge (n=53) versus management in an observation unit with stress testing (n=52). The primary end points were 30-day total charges and length of stay. Secondary end points were all-cause death, nonfatal AMI, rehospitalization for evaluation of possible AMI, and coronary revascularization at 30 days. Patients randomized to early discharge, compared with those who were admitted for observation and cardiac testing, spent less time in the hospital (median 6.3 hours versus 25.9 hours; <0.001) with an associated reduction in median total charges of care ($2953 versus $9616; <0.001). There were no deaths, AMIs, or coronary revascularizations in either group. One patient in each group was lost to follow-up.
Among patients evaluated for possible AMI in the emergency department with a modified HEART score ≤3, early discharge without stress testing as compared with transfer to an observation unit for stress testing was associated with significant reductions in length of stay and total charges, a finding that has tremendous potential national healthcare expenditure implications.
URL: http://www.clinicaltrials.gov. Unique identifier: NCT03058120.
医院对胸痛患者进行评估很常见且成本高昂。已证实，将肌钙蛋白检测纳入临床风险模型的HEART评分风险分层工具，可有效识别出很大一部分低风险患者亚组，这些患者可能无需进行负荷试验即可安全早期出院，这一策略可能对医疗保健节省开支有重大影响。
2014年2月至2015年5月期间，在亨利·福特医疗系统（密歇根州底特律市和西布卢姆菲尔德市）的2家教学医院急诊科，共有105例因急性心肌梗死（AMI）接受评估的患者，其改良HEART评分≤3（包括0小时和3小时时心肌肌钙蛋白I<0.04 ng/mL），被随机分为立即出院组（n=53）和在观察单元进行负荷试验管理组（n=52）。主要终点为30天总费用和住院时间。次要终点为全因死亡、非致命性AMI、因可能的AMI再次住院评估以及30天时的冠状动脉血运重建。与入院观察和进行心脏检测的患者相比，随机分配至早期出院的患者住院时间更短（中位数6.3小时对25.9小时；<0.001），护理总费用中位数也相应降低（2953美元对9616美元；<0.001）。两组均无死亡、AMI或冠状动脉血运重建事件。每组各有1例患者失访。
在急诊科因可能的AMI接受评估且改良HEART评分≤3的患者中，与转至观察单元进行负荷试验相比，无需负荷试验的早期出院与住院时间和总费用的显著降低相关，这一发现对国家医疗保健支出具有巨大的潜在影响。
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