Cardiology Department, NHS Fife, Kirkcaldy, UK.
Division of Clinical and Surgical Sciences, University of Edinburgh, Edinburgh, UK.
Open Heart. 2021 Nov;8(2). doi: 10.1136/openhrt-2021-001769.
Patients with suspected acute coronary syndrome and high-sensitivity cardiac troponin (hs-cTn) concentrations below the limit of detection at presentation are low risk. We aim to determine whether implementing this approach facilitates the safe early discharge of patients.
In a prospective single-centre cohort study, consecutive patients with suspected acute coronary syndrome were included before (standard care) and after (intervention) implementation of an early rule-out pathway. During standard care, myocardial infarction was ruled out if hs-cTnT concentrations were <99th centile (14 ng/L) at presentation and at 6-12 hours after symptom onset. In the intervention, patients were ruled out if hs-cTnT concentrations were <5 ng/L at presentation and symptoms present for ≥3 hours or were ≥5 ng/L and unchanged within the reference range at 3 hours. We compared duration of stay (efficacy) and all-cause death at 1 year (safety) before and after implementation.
We included 10 315 consecutive patients (64±16 years, 46% women) with 6642 (64%) and 3673 (36%) in the standard care and intervention groups, respectively. Duration of stay was reduced from 534 (IQR, 220-2279) to 390 (IQR, 218-1910) min (p<0.001) after implementation. At 1 year, all-cause death occurred in 10.9% (721 of 6642) and 10.4% (381 of 3673) of patients in the standard care group (referent) and intervention group, respectively (adjusted OR 1.02, 95% CI 0.88 to 1.18).
In patients with suspected acute coronary syndrome, implementing an early rule-out pathway using hs-cTnT concentrations <5 ng/L at presentation reduced the duration of stay in hospital without compromising safety.
对于就诊时高敏心肌肌钙蛋白（hs-cTn）浓度低于检测限的疑似急性冠状动脉综合征患者，其风险较低。本研究旨在确定采用这种方法是否有助于安全地提前对患者进行出院处理。
在一项前瞻性单中心队列研究中，连续纳入疑似急性冠状动脉综合征患者，这些患者在实施早期排除策略（干预组）之前（标准治疗组）和之后（干预组）均接受了检查。在标准治疗组中，如果就诊时 hs-cTnT 浓度＜第 99 百分位数（14ng/L）且在症状发作后 6-12 小时浓度仍＜第 99 百分位数，即可排除心肌梗死。在干预组中，如果就诊时 hs-cTnT 浓度＜5ng/L 且症状持续≥3 小时，或就诊时浓度≥5ng/L 且 3 小时内浓度在参考范围内保持不变，则可以排除患者患有心肌梗死。我们比较了策略实施前后的住院时间（疗效）和 1 年时的全因死亡率（安全性）。
共纳入 10315 例连续患者（64±16 岁，46%为女性），其中 6642 例（64%）和 3673 例（36%）患者分别在标准治疗组和干预组接受治疗。与标准治疗组（220-2279min）相比，干预组患者的住院时间从 534（IQR，220-2279）减少到 390（IQR，218-1910）min（p＜0.001）。在 1 年时，标准治疗组（参考组）和干预组患者的全因死亡率分别为 10.9%（721/6642）和 10.4%（381/3673），调整后的 OR 值为 1.02（95%CI 0.88-1.18）。
在疑似急性冠状动脉综合征患者中，采用 hs-cTnT 浓度＜5ng/L 就诊时进行早期排除策略，可缩短患者的住院时间，同时不影响安全性。
