Mosso Maria Lucia, Montemerani Sara
S.C. Medicina e Chirurgia d'Accettazione ed Urgenza (MeCAU) - Pronto Soccorso, Dipartimento Emergenza Urgenza. Ospedale S. Andrea, Vercelli, Italia.
UOC Medicina d'Urgenza e Pronto Soccorso, Dipartimento Emergenza Urgenza. Ospedale San Donato, Arezzo, Italia.
Open Access Emerg Med. 2023 Jan 19;15:29-36. doi: 10.2147/OAEM.S391929. eCollection 2023.
Chest pain in a common symptom in patients attending Emergency Department worldwide and can be related to an extensive variety of disorders, so it represents a diagnostic and logistic challenge for Emergency physicians. The aim of this study is to identify a subgroup of patients with a low pre-test probability of major adverse cardiac events, for which there is no need of troponin testing, to avoid potential harm from false-positive testing and long length stay in ED.
We retrospectively analyzed data of patients that attended ED of Siena complaining chest pain from January 2019 to August 2021. We used a modified HEART score, only evaluating history, EKG, age and risk factors. A 0-1 HEAR score was considered at very low risk for adverse cardiac events. Sensitivity, specificity, PPV, NPV and incidence of adverse cardiac events were calculated. The accuracy of HEAR score was evaluated with ROC curve. The correlation of adverse cardiac events with HEAR score 0-1 was evaluated with Fisher test.
In this study, we included 2046 patients, of which 279 were classified at very low risk. The incidence of adverse cardiac events in this population was 0.36%. Sensibility was 97.5%, sensitivity 61%, PPV 36.8%, NPV 99.1%. The AUC for global accuracy of HEAR score was 0.945. Chi-square's P value for the association between adverse cardiac events and HEAR score 0-1 was <0.001.
The draft presented in this study answers to the necessity to make a personalized path for patients attending ED with chest pain. The choice to avoid troponin testing may appear risky, but data from this study and from other similar show that a careful evaluation of clinical data and EKG allows to correctly discriminate which patients will not have adverse cardiac events, reducing the length of stay in ED.
胸痛是全球急诊科患者的常见症状，可能与多种疾病相关，因此对急诊科医生来说是一项诊断和后勤方面的挑战。本研究的目的是确定一组主要不良心脏事件预检概率较低的患者，这些患者无需进行肌钙蛋白检测，以避免假阳性检测带来的潜在危害以及在急诊科的长时间停留。
我们回顾性分析了2019年1月至2021年8月在锡耶纳急诊科因胸痛就诊的患者数据。我们使用了改良的HEART评分，仅评估病史、心电图、年龄和危险因素。HEAR评分为0 - 1被认为不良心脏事件风险极低。计算了敏感性、特异性、阳性预测值、阴性预测值和不良心脏事件的发生率。用ROC曲线评估HEAR评分的准确性。用Fisher检验评估不良心脏事件与HEAR评分为0 - 1的相关性。
本研究纳入2046例患者，其中279例被分类为极低风险。该人群中不良心脏事件的发生率为0.36%。敏感性为97.5%，特异性为61%，阳性预测值为36.8%，阴性预测值为99.1%。HEAR评分总体准确性的AUC为0.945。不良心脏事件与HEAR评分为0 - 1之间关联的卡方P值<0.001。
本研究中提出的方案满足了为因胸痛就诊于急诊科的患者制定个性化路径的必要性。避免肌钙蛋白检测的选择可能看似有风险，但本研究及其他类似研究的数据表明，对临床数据和心电图进行仔细评估能够正确区分哪些患者不会发生不良心脏事件，从而缩短在急诊科的停留时间。
