Alshaikh Lamees M, Apple Fred S, Christenson Robert H, deFilippi Christopher R, Limkakeng Alexander T, McCord James, Nowak Richard M, Singer Adam J, Peacock W Frank
Baylor College of Medicine Houston Texas USA.
Hennepin County Medical Center University of Minnesota Minneapolis Minnesota USA.
J Am Coll Emerg Physicians Open. 2022 Nov 17;3(6):e12844. doi: 10.1002/emp2.12844. eCollection 2022 Dec.
Although some emergency department risk stratification tools consider non-specific ECG findings as an aid in disposition decisions, their clinical value in patients with an initially low high-sensitivity cardiac troponin I (hsTnI) is unclear.
Our purpose was to determine if non-specific ECG (ns-ECG) findings are associated with 30-day major adverse cardiac events (MACE) in ED patients presenting with suspected acute coronary syndromes (ACS) who have a low initial hsTnI.
Using the prospective Siemens Atellica hsTnI Food and Drug Administration submission observational database, we conducted a retrospective cohort study of the association between ns-ECG findings (defined as left bundle branch block [LBBB], ST depression [STD], or T-wave inversions [TWI]) and 30-day MACE (death, myocardial infarction, heart failure hospitalization, or coronary revascularization). Eligible patients presented with suspected ACS to one of 29 US EDs from April 2015 to April 2016, had stable vital signs, a blood sample for hsTnI (Siemen's Atellica, Siemens Healthineers, Inc, Malvern, PA) obtained at 1, 3, and 6 hours after ED presentation, and were followed for 30 days. The relationship between 30-day outcome, initial hsTnI, and ns-ECG was evaluated using chi-square testing.
Of 2676 enrolled, 1313 patients met the inclusion criteria and are included in the analysis. Median (interquartile range) age was 62 years (54, 72), 54% were male, with 56% white, and 39% African American. Median (interquartile range) times from symptom onset to presentation and presentation to specimen collection were 92 (0, 216) and 146 (117, 177) minutes, respectively. The most common presenting symptoms were chest pain (84%), followed by dyspnea (9%). ECG findings were categorized as T-wave inversion or non-specific T wave changes (42%), ST depression ns-ECG ST changes (16%), or LBBB (2%). Thirty-day MACE occurred in 72 (5.5%) patients, with coronary revascularization (35 patients, 2.7%) and heart failure (25 patients, 1.9%) being the most frequent outcomes. In patients with an initial hsTnI below the limit of quantitation (LOQ) of 2.5 ng/L (n = 449), there was no association between ns-ECG changes and 30-day MACE ( = 0.42). If the hsTnI was ≥LOQ (2.5 ng/L), there were increased rates of 30-day MACE and ns-ECG findings ( = 0.01).
In ED suspected ACS patients without unstable vital signs, and an initial hsTnI less than the LOQ (2.5 ng/L), ns-ECG findings are not associated with 30-day major adverse cardiac events. The use of ns-ECG findings in ACS disposition should be considered in the context of hsTnI levels.
尽管一些急诊科风险分层工具将非特异性心电图表现作为处置决策的辅助依据，但其在初始高敏心肌肌钙蛋白I（hsTnI）水平较低的患者中的临床价值尚不清楚。
我们的目的是确定在疑似急性冠状动脉综合征（ACS）且初始hsTnI水平较低的急诊科患者中，非特异性心电图（ns-ECG）表现是否与30天主要不良心脏事件（MACE）相关。
利用前瞻性西门子Atellica hsTnI食品药品监督管理局提交的观察性数据库，我们对ns-ECG表现（定义为左束支传导阻滞[LBBB]、ST段压低[STD]或T波倒置[TWI]）与30天MACE（死亡、心肌梗死、心力衰竭住院或冠状动脉血运重建）之间的关联进行了一项回顾性队列研究。符合条件的患者在2015年4月至2016年4月期间因疑似ACS就诊于美国29家急诊科之一，生命体征稳定，在急诊科就诊后1、3和6小时采集了用于检测hsTnI的血样（西门子Atellica，西门子医疗解决方案公司，宾夕法尼亚州马尔伯勒），并随访30天。使用卡方检验评估30天结局、初始hsTnI和ns-ECG之间的关系。
在纳入的2676例患者中，1313例患者符合纳入标准并纳入分析。年龄中位数（四分位间距）为62岁（54，72），54%为男性，56%为白人，39%为非裔美国人。从症状发作到就诊以及从就诊到标本采集的时间中位数（四分位间距）分别为92（0，216）分钟和146（117，177）分钟。最常见的就诊症状是胸痛（84%），其次是呼吸困难（9%）。心电图表现分为T波倒置或非特异性T波改变（42%）、ST段压低非特异性ST改变（16%）或LBBB（2%）。72例（5.5%）患者发生了30天MACE，最常见的结局是冠状动脉血运重建（35例患者，2.7%）和心力衰竭（25例患者，1.9%）。在初始hsTnI低于定量下限（LOQ）2.5 ng/L的患者（n = 449）中，ns-ECG改变与30天MACE之间无关联（P = 0.42）。如果hsTnI≥LOQ（2.5 ng/L），30天MACE和ns-ECG表现的发生率会增加（P = 0.01）。
在无生命体征不稳定且初始hsTnI低于LOQ（2.5 ng/L）的急诊科疑似ACS患者中，ns-ECG表现与30天主要不良心脏事件无关。在ACS处置中使用ns-ECG表现应结合hsTnI水平来考虑。
