Department of Emergency Medicine, Yale University, New Haven, CT, USA.
Department of Cardiology, Robert-Bosch-Krankenhaus, Stuttgart, Germany.
Clin Ther. 2018 Nov;40(11):1920-1930. doi: 10.1016/j.clinthera.2018.09.010. Epub 2018 Oct 27.
Chest pain stands as one of the most frequent patient presentations in the emergency department (ED). Despite established diagnostic algorithms for identifying several important causes of chest pain, such as acute myocardial infarction (AMI), aortic dissection, and pulmonary embolism, guidance on managing patients with recurrent chest pain, one of the top 3 reasons for repeated hospitalization in the United States, is less defined. The assessment of symptoms, serial ECG, and necrosis biomarkers plays a major role in patient management. Notably, the recently introduced high-sensitivity troponin T (hs-TnT) assay is helping to identify ischemia in patients previously undiagnosed by conventional testing. In Europe, with the use of this assay for over a decade, the identification of patients with AMI has substantially increased, particularly of patients with type 2 AMI, which is seen in the absence of atherosclerotic obstruction of the epicardial coronaries on angiography. Use of hs-TnT is in particular relevant in women, in whom the use of a sex-specific threshold for elevated hs-TnT has almost doubled the diagnosis of AMI. With the advent of the hs-TnT assay in the United States in 2017, a similar phenomenon is expected. Thus, it is important to learn from the European experience and to develop sex-specific nuanced algorithms for the evaluation of additional causes of myocardial ischemia/necrosis, such as coronary artery vasomotor disorders and coronary microvascular dysfunction. The latter has a high prevalence among symptomatic women presenting to the ED, a group in whom recurrent chest pain is common. This commentary describes the tools available for diagnosing epicardial- and non-epicardial-related myocardial ischemia in patients with recurrent chest pain in the ED setting. A sex-specific, nuanced approach applied to select groups of patients being observed in the ED has the potential to reduce admissions and to allow for the initiation of timely, appropriate medical treatment and outpatient follow-up in an at-risk population. The costs and availability of advanced diagnostics may pose some limitation to the widespread adoption of such protocols.
胸痛是急诊科（ED）最常见的患者就诊原因之一。尽管已经建立了用于识别几种重要胸痛原因的诊断算法，例如急性心肌梗死（AMI）、主动脉夹层和肺栓塞，但对于管理复发性胸痛患者的指导，美国重复住院的前 3 大原因之一，定义不明确。症状评估、连续心电图和坏死生物标志物在患者管理中起着重要作用。值得注意的是，最近推出的高敏肌钙蛋白 T（hs-TnT）检测有助于识别以前通过常规检测无法诊断的缺血患者。在欧洲，该检测已使用了十多年，AMI 患者的识别数量显著增加，特别是 2 型 AMI 患者，其在血管造影上未见心外膜冠状动脉粥样硬化阻塞。hs-TnT 的使用尤其适用于女性，其中使用针对 hs-TnT 升高的性别特异性阈值几乎使 AMI 的诊断增加了一倍。随着 2017 年 hs-TnT 检测在美国的出现，预计也会出现类似的情况。因此，从欧洲的经验中吸取教训，并为评估冠状动脉血管舒缩障碍和冠状动脉微血管功能障碍等心肌缺血/坏死的其他原因制定性别特异性精细算法非常重要。后者在出现反复胸痛的有症状女性中很常见，且在这群人中的患病率很高。本评论描述了在 ED 环境中用于诊断复发性胸痛患者心外膜和非心外膜相关心肌缺血的可用工具。在观察的特定患者群体中应用性别特异性、精细的方法有可能减少住院人数，并使高危人群能够及时进行适当的医疗治疗和门诊随访。高级诊断的成本和可用性可能会对这些方案的广泛采用构成一些限制。
