Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.L., K.P.A., N.J.P., C.L.H., B.A., D.B.M., P.S.D.).
Vanderbilt University Medical Center (A.L.).
Circ Cardiovasc Qual Outcomes. 2022 May;15(5):e008298. doi: 10.1161/CIRCOUTCOMES.121.008298. Epub 2022 Apr 4.
Patients evaluated for coronary artery disease have a range of symptoms and underlying risk. The relationships between patient-described symptoms, clinician conclusions, and subsequent clinical management and outcomes remain incompletely described.
In this secondary analysis, we examined the association between 4 types of presenting symptoms (substernal/left-sided chest pain, other chest/neck/arm pain, dyspnea, and other symptoms) and patient risk, noninvasive test results, clinical management, and outcomes for stable outpatients randomized in the PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) trial. Multivariable regression models were used to evaluate differences in noninvasive test result, all-cause death/myocardial infarction/unstable angina hospitalization and cardiovascular death/myocardial infarction by symptom type.
Among 9996 patients, most presented with chest pain (47.2% substernal, 29.2% other), followed by dyspnea (14.9%), and other symptoms (8.7%). Patients with dyspnea were older (median age 63 versus 60, ≤0.02) with higher baseline risk (78.2% with atherosclerotic cardiovascular disease >7.5% versus 67.6%, ≤0.02). Using patients with substernal chest pain as a reference, there was no difference in noninvasive test positivity across symptom groups (all >0.05), but test-positive patients with dyspnea (adjusted odds ratio, 0.66 [95% CI, 0.51-0.85]) or other symptoms (adjusted odds ratio, 0.65 [95% CI, 0.47-0.90]) were less likely to be referred for cardiac catheterization. While symptom type alone was not associated with outcomes, symptom presentation with chest pain or dyspnea did modify the association between a positive noninvasive test and clinical outcome (interaction =0.025 for both all-cause death/myocardial infarction/unstable angina hospitalization and cardiovascular death/MI).
Among low-risk outpatients evaluated for coronary artery disease, typicality of symptoms was not closely associated with higher baseline risk but was related to differences in processes of care and the prognostic value of a positive test. Adverse events were not associated with clinician risk estimates or symptoms alone. These unexpected findings highlight the limitation of relying solely on symptom presentation or clinician risk estimation to evaluate patients for suspected coronary artery disease.
URL: https://www.
gov; Unique identifier: NCT01174550.
评估冠状动脉疾病的患者有一系列症状和潜在风险。患者描述的症状、临床医生的结论以及随后的临床管理和结局之间的关系仍未完全描述。
在这项二次分析中，我们检查了 4 种表现症状（胸骨后/左侧胸痛、其他胸部/颈部/手臂疼痛、呼吸困难和其他症状）与患者风险、非侵入性检查结果、临床管理和稳定门诊患者的结局之间的关联，这些患者是在 PROMISE（前瞻性多中心成像研究评估胸痛）试验中随机分组的。多变量回归模型用于评估不同症状类型的非侵入性检查结果、全因死亡/心肌梗死/不稳定型心绞痛住院和心血管死亡/心肌梗死之间的差异。
在 9996 名患者中，大多数患者出现胸痛（47.2%胸骨后，29.2%其他部位），其次是呼吸困难（14.9%）和其他症状（8.7%）。呼吸困难患者年龄较大（中位数年龄 63 岁与 60 岁，≤0.02），基线风险较高（78.2%有动脉粥样硬化性心血管疾病>7.5%与 67.6%，≤0.02）。以胸骨后胸痛患者为参考，各症状组之间的非侵入性检查阳性率无差异（均>0.05），但呼吸困难（调整比值比，0.66[95%CI，0.51-0.85]）或其他症状（调整比值比，0.65[95%CI，0.47-0.90]）阳性患者接受心脏导管检查的可能性较小。虽然症状类型本身与结局无关，但胸痛或呼吸困难的症状表现确实改变了阳性非侵入性检查与临床结局之间的关联（交互作用=0.025，均用于全因死亡/心肌梗死/不稳定型心绞痛住院和心血管死亡/心肌梗死）。
在低风险的门诊患者中，评估冠状动脉疾病的症状典型性与较高的基线风险无密切关联，但与护理过程中的差异和阳性检查的预后价值有关。不良事件与临床医生的风险估计或单独的症状无关。这些意外发现强调了仅依靠症状表现或临床医生的风险估计来评估疑似冠状动脉疾病患者的局限性。
网址：https://www.
gov；唯一标识符：NCT01174550。
