Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia; School of Medicine, The University of Queensland, Brisbane, Queensland, Australia.
Emergency Department, South Meade Hospital, North Bristol National Health Service Trust, Bristol, United Kingdom.
Ann Emerg Med. 2018 Apr;71(4):439-451.e3. doi: 10.1016/j.annemergmed.2017.10.030. Epub 2017 Dec 13.
This diagnostic accuracy study describes the performance of 5 accelerated chest pain pathways, calculated with the new Beckman's Access high-sensitivity troponin I assay.
High-sensitivity troponin I was measured with presentation and 2-hour blood samples in 1,811 patients who presented to an emergency department (ED) in Australia. Patients were classified as being at low risk according to 5 rules: modified accelerated diagnostic protocol to assess patients with chest pain symptoms using troponin as the only biomarker (m-ADAPT), the Emergency Department Assessment of Chest Pain Score (EDACS) pathway, the History, ECG, Age, Risk Factors, and Troponin (HEART) pathway, the No Objective Testing Rule, and the new Vancouver Chest Pain Rule. Endpoints were 30-day acute myocardial infarction and acute coronary syndrome. Measures of diagnostic accuracy for each rule were calculated.
Data included 96 patients (5.3%) with acute myocardial infarction and 139 (7.7%) with acute coronary syndrome. The new Vancouver Chest Pain Rule and No Objective Testing Rule had high sensitivity for acute myocardial infarction (100%; 95% confidence interval [CI] 96.2% to 100% for both) and acute coronary syndrome (98.6% [95% CI 94.9% to 99.8%] and 99.3% [95% CI 96.1% to 100%]). The m-ADAPT, EDACS, and HEART pathways also yielded high sensitivity for acute myocardial infarction (96.9% [95% CI 91.1% to 99.4%] for m-ADAPT and 97.9% [95% CI 92.7% to 99.7%] for EDACS and HEART), but lower sensitivity for acute coronary syndrome (≤95.0% for all). The m-ADAPT, EDACS, and HEART rules classified more patients as being at low risk (64.3%, 62.5%, and 49.8%, respectively) than the new Vancouver Chest Pain Rule and No Objective Testing Rule (28.2% and 34.5%, respectively).
In this cohort with a low prevalence of acute myocardial infarction and acute coronary syndrome, using the Beckman's Access high-sensitivity troponin I assay with the new Vancouver Chest Pain Rule or No Objective Testing Rule enabled approximately one third of patients to be safely discharged after 2-hour risk stratification with no further testing. The EDACS, m-ADAPT, or HEART pathway enabled half of ED patients to be rapidly referred for objective testing.
本诊断准确性研究描述了 5 种加速胸痛路径的性能，这些路径是使用新的贝克曼 Access 高敏肌钙蛋白 I 检测方法计算得出的。
在澳大利亚的一个急诊科，对 1811 名出现胸痛症状的患者进行了高敏肌钙蛋白 I 的检测，检测时间分别为就诊时和 2 小时后。根据以下 5 个规则对患者进行低危分类：改良加速诊断方案（m-ADAPT），使用肌钙蛋白作为唯一生物标志物评估胸痛症状患者；急诊胸痛评分（EDACS）路径；病史、心电图、年龄、危险因素和肌钙蛋白（HEART）路径；无客观检测规则；以及新的温哥华胸痛规则。终点是 30 天内发生急性心肌梗死和急性冠脉综合征。计算每个规则的诊断准确性指标。
数据包括 96 例（5.3%）急性心肌梗死和 139 例（7.7%）急性冠脉综合征患者。新的温哥华胸痛规则和无客观检测规则对急性心肌梗死具有高敏感性（100%；95%置信区间 [CI] 96.2%至 100%）和急性冠脉综合征（98.6%[95%CI 94.9%至 99.8%]和 99.3%[95%CI 96.1%至 100%]）。m-ADAPT、EDACS 和 HEART 路径对急性心肌梗死也具有高敏感性（m-ADAPT 为 96.9%[95%CI 91.1%至 99.4%]，EDACS 和 HEART 为 97.9%[95%CI 92.7%至 99.7%]），但对急性冠脉综合征的敏感性较低（≤95.0%）。m-ADAPT、EDACS 和 HEART 规则将更多的患者归类为低危（分别为 64.3%、62.5%和 49.8%），而新的温哥华胸痛规则和无客观检测规则归类为低危的患者比例（分别为 28.2%和 34.5%）。
在本研究队列中，急性心肌梗死和急性冠脉综合征的患病率较低，使用贝克曼 Access 高敏肌钙蛋白 I 检测，结合新的温哥华胸痛规则或无客观检测规则，在 2 小时风险分层后，大约三分之一的患者无需进一步检查即可安全出院。EDACS、m-ADAPT 或 HEART 路径可使一半的急诊科患者快速进行客观检查。
