Research and Evaluation Department, Kaiser Permanente Southern California, Pasadena, CA, USA.
Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, CA, Pasadena, USA.
J Gen Intern Med. 2022 Mar;37(4):745-752. doi: 10.1007/s11606-021-06841-2. Epub 2021 May 14.
Chest pain is the top reason for hospitalization/observation in the USA, but it is unclear if this strategy improves patient outcomes.
The objective of this study was to compare 30-day outcomes for patients admitted versus discharged after a negative emergency department (ED) evaluation for suspected acute coronary syndrome.
A retrospective, multi-site, cohort study of adult encounters with chest pain presenting to one of 13 Kaiser Permanente Southern California EDs between January 1, 2015, and December 1, 2017. Instrumental variable analysis was used to mitigate potential confounding by unobserved factors.
All adult patients presenting to an ED with chest pain, in whom an acute myocardial infarction was not diagnosed in the ED, were included.
The primary outcome was 30-day acute myocardial infarction or all-cause mortality, and secondary outcomes included 30-day revascularization and major adverse cardiac events.
In total, 77,652 patient encounters were included in the study (n=11,026 admitted, 14.2%). Three hundred twenty-two (0.4%) had an acute myocardial infarction (n=193, 0.2%) or death (n=137, 0.2%) within 30 days of ED visit (1.5% hospitalized versus 0.2% discharged). Very few (0.3%) patients underwent coronary revascularization within 30 days (0.7% hospitalized versus 0.2% discharged). Instrumental variable analysis found no adjusted differences in 30-day patient outcomes between the hospitalized cohort and those discharged (risk reduction 0.002, 95% CI -0.002 to 0.007). Similarly, there were no differences in coronary revascularization (risk reduction 0.003, 95% CI -0.002 to 0.007).
Among ED patients with chest pain not diagnosed with an acute myocardial infarction, risk of major adverse cardiac events is quite low, and there does not appear to be any benefit in 30-day outcomes for those admitted or observed in the hospital compared to those discharged with outpatient follow-up.
胸痛是美国住院/观察的首要原因，但目前尚不清楚这种策略是否能改善患者的预后。
本研究旨在比较疑似急性冠状动脉综合征患者经急诊科（ED）阴性评估后住院与出院患者的 30 天结局。
这是一项回顾性、多地点、队列研究，纳入了 2015 年 1 月 1 日至 2017 年 12 月 1 日期间在 Kaiser Permanente 南加州 13 个 ED 就诊的胸痛成年患者。采用工具变量分析来减轻未观察到的因素造成的潜在混杂。
所有因胸痛就诊于 ED、未在 ED 诊断出急性心肌梗死的成年患者均被纳入。
主要结局为 30 天内发生急性心肌梗死或全因死亡率，次要结局包括 30 天内血运重建和主要不良心脏事件。
本研究共纳入 77652 例患者就诊（住院 11026 例，占 14.2%）。322 例（0.4%）患者在 ED 就诊后 30 天内发生急性心肌梗死（193 例，0.2%）或死亡（137 例，0.2%）（住院者为 1.5%，出院者为 0.2%）。极少数（0.3%）患者在 30 天内行血运重建（住院者为 0.7%，出院者为 0.2%）。工具变量分析发现，住院组与出院组患者 30 天结局无调整差异（风险降低 0.002，95%CI-0.002 至 0.007）。同样，血运重建也无差异（风险降低 0.003，95%CI-0.002 至 0.007）。
在 ED 因胸痛就诊且未诊断出急性心肌梗死的患者中，主要不良心脏事件的风险较低，与出院后门诊随访相比，住院或留观患者在 30 天结局方面似乎没有任何获益。
