中危患者的主要不良心脏事件发生率：既往冠心病是否重要？
Major adverse cardiac event rates in moderate-risk patients: Does prior coronary disease matter?
机构信息
Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.
Department of Biostatistics and Data Science, Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.
出版信息
Acad Emerg Med. 2022 Jun;29(6):688-697. doi: 10.1111/acem.14462. Epub 2022 Mar 31.
BACKGROUND
Despite negative troponins and nonischemic electrocardiograms (ECGs), patients at moderate risk for acute coronary syndrome (ACS) are frequently admitted. The objective of this study was to describe the major adverse cardiac event (MACE) rate in moderate-risk patients and how it differs based on history of coronary artery disease (CAD).
METHODS
A secondary analysis of the HEART Pathway implementation study was conducted. This prospective interrupted time-series study accrued adults with possible ACS from three sites (November 2013-January 2016). This analysis excluded low-risk patients determined by emergency providers' HEART Pathway assessments. Non-low-risk patients were further classified as high risk, based on elevated troponin measures or ischemic ECG findings or as moderate risk, based on HEAR score ≥ 4, negative troponin measures, and a nonischemic ECG. Moderate-risk patients were then stratified by the presence or absence of prior CAD (MI, revascularization, or ≥70% coronary stenosis). MACE (death, myocardial infarction, or revascularization) at 30 days was determined from health records, insurance claims, and death index data. MACE rates were compared among groups using a chi-square test and likelihood ratios (LRs) were calculated.
RESULTS
Among 4,550 patients with HEART Pathway assessments, 24.8% (1,130/4,550) were high risk and 37.7% (1715/4550) were moderate risk. MACE at 30 days occurred in 3.1% (53/1,715; 95% confidence interval [CI] = 2.3% to 4.0%) of moderate-risk patients. Among moderate-risk patients, MACE occurred in 7.1% (36/508, 95% CI = 5.1% to 9.8%) of patients with known CAD versus 1.4% (17/1,207, 95% CI = 0.9% to 2.3%) in patients without known prior CAD (p < 0.0001). The negative LR for 30-day MACE among moderate-risk patients without prior CAD was 0.08 (95% CI = 0.05 to 0.12).
CONCLUSION
MACE rates at 30 days were low among moderate-risk patients but were significantly higher among those with prior CAD.
背景
尽管肌钙蛋白和非缺血性心电图（ECG）为阴性，具有急性冠状动脉综合征（ACS）中度风险的患者仍常被收入院。本研究的目的是描述中度风险患者的主要不良心脏事件（MACE）发生率，以及该发生率如何因冠心病（CAD）病史而异。
方法
对 HEART 通路实施研究进行二次分析。这是一项前瞻性的中断时间序列研究，从三个地点（2013 年 11 月至 2016 年 1 月）招募可能患有 ACS 的成年人。该分析排除了根据急救提供者的 HEART 通路评估确定的低风险患者。非低风险患者进一步根据升高的肌钙蛋白测量值或缺血性 ECG 结果被分类为高危，或根据 HEAR 评分≥4、肌钙蛋白测量值阴性和非缺血性 ECG 被分类为中危。然后根据是否存在既往 CAD（心肌梗死、血运重建或≥70%的冠状动脉狭窄）将中危患者进一步分层。30 天时的 MACE（死亡、心肌梗死或血运重建）由健康记录、保险索赔和死亡索引数据确定。使用卡方检验比较各组之间的 MACE 发生率，并计算似然比（LR）。
结果
在接受 HEART 通路评估的 4550 名患者中，24.8%（1130/4550）为高危，37.7%（1715/4550）为中危。30 天时发生 MACE 的比例为 3.1%（53/1715；95%置信区间 [CI]为 2.3%至 4.0%）。在中危患者中，已知 CAD 患者的 MACE 发生率为 7.1%（36/508，95% CI 为 5.1%至 9.8%），而无已知既往 CAD 患者的 MACE 发生率为 1.4%（17/1207，95% CI 为 0.9%至 2.3%）（p<0.0001）。无既往 CAD 的中危患者 30 天内 MACE 的负似然比为 0.08（95% CI 为 0.05 至 0.12）。
结论
中危患者 30 天内的 MACE 发生率较低，但既往有 CAD 的患者 MACE 发生率显著升高。
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