Yu Christopher, Sheriff Javed, Ng Austin, Brazete Susana, Gullick Janice, Brieger David, Kritharides Leonard, Lowe Harry C
Department of Cardiology, Concord Repatriation General Hospital, Sydney, NSW, Australia.
Department of Cardiology, Concord Repatriation General Hospital, Sydney, NSW, Australia; University of Sydney, Sydney, NSW, Australia.
Heart Lung Circ. 2018 Nov;27(11):1376-1380. doi: 10.1016/j.hlc.2017.11.006. Epub 2017 Dec 11.
Chest pain is the second most common presenting symptom to emergency departments (ED) in Australia, although up to 85% of these patients do not have an acute coronary syndrome (ACS). Cardiologist-led rapid access chest pain clinics (RACPC) have been proposed overseas to assist in the management of such patients, with prompt outpatient assessment if patients are deemed low risk and discharged from the ED. The use of RACPCs in Australia has been only recently proposed; we therefore sought to examine one such RACPC in an Australian context.
1133 consecutive patients were seen at a metropolitan RACPC, between August 2008 and February 2017. There was a high preponderance of cardiovascular risk factors. Exercise stress testing (EST) was the default investigation upon discharge from ED, with a total of 1038 ESTs performed in 1113 patients (93%), with low numbers of other functional tests, and a small, but increasing number of coronary computed tomography (CT) scans performed over this period. Eighteen patients subsequently underwent revascularisation (1.6% of the total cohort), and none of these patients were readmitted at any time with an ACS between the interval of their index ED presentation to these investigations or treatments. Five (0.4%) patients represented to ED within 48hours, none due to a cardiovascular cause. A total of 24 (2.1%) patients represented between 2 and 28 days, with none of these due to an ACS.
Following ED assessment of acute chest pain as low risk-with direct ED referral for exercising testing followed by RACPC review-results in very low readmission rates at 48hours and at 28 days. Moreover, these readmissions were almost always not of cardiovascular aetiology, and occurred despite relatively longer waiting periods for both EST (8 days) and between EST and RACPC review (11 days), than the prespecified 72 to 96hours as defined by the clinic protocol. Further investigation into this model of care in Australia is suggested.
胸痛是澳大利亚急诊科第二常见的就诊症状，尽管这些患者中高达85%没有急性冠状动脉综合征（ACS）。海外已提议由心脏病专家主导的快速胸痛诊所（RACPC）来协助管理此类患者，如果患者被认为风险较低，可在急诊科迅速进行门诊评估并出院。澳大利亚最近才提议使用RACPC；因此，我们试图在澳大利亚的背景下研究这样一个RACPC。
2008年8月至2017年2月期间，一家大都市的RACPC共接待了1133例连续患者。心血管危险因素的比例很高。运动负荷试验（EST）是急诊科出院后的默认检查，1113例患者（93%）共进行了1038次EST，其他功能检查数量较少，在此期间冠状动脉计算机断层扫描（CT）扫描的数量虽少但呈上升趋势。18例患者随后接受了血运重建（占总队列的1.6%），在这些患者从首次急诊科就诊到这些检查或治疗的间隔期间，没有患者因ACS再次入院。5例（0.4%）患者在48小时内再次到急诊科就诊，均非心血管原因。共有24例（2.1%）患者在2至28天内再次就诊，均非ACS所致。
在急诊科对急性胸痛评估为低风险后——直接由急诊科转诊进行运动试验，随后由RACPC进行复查——48小时和28天的再入院率非常低。此外，这些再入院几乎都不是心血管病因，尽管EST的等待时间（8天）以及EST与RACPC复查之间的等待时间（11天）比临床方案规定 的预定72至96小时要长。建议对澳大利亚的这种护理模式进行进一步研究。
