Howell Stacey J, Bui Jonathan, Thevakumar Balasingam, Amsterdam Ezra A
Department of Internal Medicine, University of California Davis Medical Center, Sacramento, California.
Division of Cardiovascular Medicine, University of California Davis Medical Center, Sacramento, California.
Am J Cardiol. 2018 Apr 1;121(7):825-829. doi: 10.1016/j.amjcard.2017.12.030. Epub 2018 Jan 10.
There are few data on the utility of physician selection of cardiac tests, including no-test, in a chest pain unit (CPU) to rule out acute coronary syndrome in low-risk patients without a history of coronary artery disease. We analyzed consecutive low-risk patients admitted to our CPU between 2012 and 2014 and determined the proportion of patients selected for testing, the type of initial cardiac test selected, and the incidence of major adverse cardiac events (MACEs) at 30 days and 6 months. The study group comprised 619 patients: mean age 57 years (27 to 92), 332 women (54%), and 360 (58%) with multiple cardiac risk factors. Cardiac testing included 283 no-test (46%); 179 exercise treadmill (29%); 113 myocardial perfusion stress scintigraphy (18%); <10% each for exercise stress echocardiography and coronary angiography. Testing was negative in 296 (88%), nondiagnostic in 30 (9%), and positive in 10 patients (3%). There were no MACEs at 30 days in any patients, and at 6 months, MACEs were 5 (1.1%). Length of stay was less in no-test than in tested patients (5.4 hours vs 9.8 hours, p <0.0001), and there was no difference in incidence of MACE at 6 months in no-test vs tested patients (2 MACEs vs 3 MACEs). Physician selection of cardiac tests, including no-test, promptly identified patients at low risk of acute coronary syndrome who could be safely and rapidly discharged from the CPU. Exclusion of cardiac testing shortened length of stay and was not associated with increase in MACE at 6 months.
关于在胸痛单元（CPU）中由医生选择心脏检查（包括不进行检查）以排除无冠状动脉疾病史的低风险患者急性冠状动脉综合征的效用，相关数据很少。我们分析了2012年至2014年间入住我们胸痛单元的连续低风险患者，确定了被选进行检查的患者比例、所选初始心脏检查的类型以及30天和6个月时主要不良心脏事件（MACE）的发生率。研究组包括619名患者：平均年龄57岁（27至92岁），332名女性（54%），360名（58%）有多种心脏危险因素。心脏检查包括283例不进行检查（46%）；179例运动平板试验（29%）；113例心肌灌注负荷闪烁显像（18%）；运动负荷超声心动图和冠状动脉造影各占不到10%。检查结果为阴性的有296例（88%），未明确诊断的有30例（9%），阳性的有10例（3%）。30天时所有患者均未发生MACE，6个月时，MACE发生率为5例（1.1%）。不进行检查的患者住院时间比进行检查的患者短（5.4小时对9.8小时，p<0.0001），6个月时不进行检查的患者与进行检查的患者MACE发生率无差异（2例MACE对3例MACE）。由医生选择心脏检查，包括不进行检查，能迅速识别出急性冠状动脉综合征低风险患者，这些患者可从胸痛单元安全、快速出院。排除心脏检查可缩短住院时间，且与6个月时MACE增加无关。
