Department of Emergency Medicine, Wake Forest School of Medicine, USA.
Department of Emergency Medicine, Wake Forest School of Medicine, USA.
Am J Emerg Med. 2021 Sep;47:248-252. doi: 10.1016/j.ajem.2021.04.073. Epub 2021 Apr 26.
Expediting the measurement of serum troponin by leveraging EMS blood collection could reduce the diagnostic time for patients with acute chest pain and help address Emergency Department (ED) overcrowding. However, this practice has not been examined among an ED chest pain patient population in the United States.
A prospective observational cohort study of adults with non-traumatic chest pain without ST-segment elevation myocardial infarction was conducted in three EMS agencies between 12/2016-4/2018. During transport, paramedics obtained a patient blood sample that was sent directly to the hospital core lab for troponin measurement. On ED arrival HEART Pathway assessments were completed by ED providers as part of standard care. ED providers were blinded to troponin results from EMS blood samples. To evaluate the potential impact on length of stay (LOS), the time difference between EMS blood draw and first clinical ED draw was calculated. To determine the safety of using troponin measures from EMS blood samples, the diagnostic performance of the HEART Pathway for 30-day major adverse cardiac events (MACE: composite of cardiac death, myocardial infarction (MI), coronary revascularization) was determined using EMS troponin plus arrival ED troponin and EMS troponin plus a serial 3-h ED troponin.
The use of EMS blood samples for troponin measures among 401 patients presenting with acute chest pain resulted in a mean potential reduction in LOS of 72.5 ± SD 35.7 min. MACE at 30 days occurred in 21.0% (84/401), with 1 cardiac death, 78 MIs, and 5 revascularizations without MI. Use of the HEART Pathway with EMS and ED arrival troponin measures yielded a NPV of 98.0% (95% CI: 89.6-100). NPV improved to 100% (95% CI: 92.9-100) when using the EMS and 3-h ED troponin measures.
EMS blood collection used for core lab ED troponin measures could significantly reduce ED LOS and appears safe when integrated into the HEART Pathway.
通过利用急诊医疗服务（EMS）采集血液来加速检测血清肌钙蛋白，可以缩短急性胸痛患者的诊断时间，并有助于解决急诊部（ED）过度拥挤的问题。然而，这种做法在美国的 ED 胸痛患者人群中尚未得到检验。
本研究是一项在美国三个 EMS 机构中开展的、针对非创伤性胸痛且无 ST 段抬高型心肌梗死的成年患者的前瞻性观察性队列研究。在转运过程中，护理人员采集了患者的血液样本，直接送到医院核心实验室进行肌钙蛋白检测。在 ED 到达时，ED 医护人员根据标准护理流程完成 HEART 评分评估。ED 医护人员对 EMS 血液样本中的肌钙蛋白结果不了解。为了评估对住院时间（LOS）的潜在影响，计算了 EMS 采血与首次 ED 临床采血之间的时间差。为了确定使用 EMS 血液样本中的肌钙蛋白测量值的安全性，使用 EMS 肌钙蛋白加 ED 到达时的肌钙蛋白和 EMS 肌钙蛋白加连续 3 小时 ED 肌钙蛋白评估了 HEART 评分对 30 天内主要不良心脏事件（MACE：包括心源性死亡、心肌梗死（MI）、冠状动脉血运重建）的诊断性能。
在 401 名因急性胸痛就诊的患者中使用 EMS 血液样本进行肌钙蛋白测量，平均潜在 LOS 缩短了 72.5 ± 35.7 分钟。30 天内发生 MACE 的比例为 21.0%（84/401），包括 1 例心源性死亡、78 例 MI 和 5 例非 MI 血运重建。使用 HEART 评分结合 EMS 和 ED 到达时的肌钙蛋白测量值，NPV 为 98.0%（95%CI：89.6-100）。当使用 EMS 和 3 小时 ED 肌钙蛋白测量值时，NPV 提高至 100%（95%CI：92.9-100）。
EMS 血液采集用于 ED 核心实验室肌钙蛋白测量，可以显著缩短 ED LOS，当整合到 HEART 评分中时似乎是安全的。
