Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
Am J Emerg Med. 2023 Oct;72:64-71. doi: 10.1016/j.ajem.2023.07.014. Epub 2023 Jul 13.
Among persons presenting to the emergency department with suspected acute myocardial infarction (MI), cardiac troponin (cTn) testing is commonly used to detect acute myocardial injury. Accelerated diagnostic protocols (ADPs) guide clinicians to integrate cTn results with other clinical information to decide whether to order further diagnostic testing.
To determine the change in the rate and yield of stress test or coronary CT angiogram following cTn measurement in patients with chest pain presenting to the emergency department pre- and post-transition to a high-sensitivity (hs-cTn) assay in an updated ADP.
Using electronic health records, we examined visits for chest pain at five emergency departments affiliated with an integrated academic health system 1-year pre- and post-hs-cTn assay transition. Outcomes included stress test or coronary imaging frequency, ADP compliance among those with additional testing, and diagnostic yield (ratio of positive tests to total tests).
There were 7564 patient-visits for chest pain, including 3665 in the pre- and 3899 in the post-period. Following the updated ADP using hs-cTn, 862 (23.5 per 100 patient visits) visits led to subsequent testing versus 1085 (27.8 per 100 patient visits) in the pre-hs-cTn period, (P < 0.001). Among those who were tested, the protocol-compliant rate fell from 80.9% to 46.5% (P < 0.001), but the yield of those tests rose from 24.5% to 29.2% (P = 0.07). Among tests that were noncompliant with ADP guidance, yield was similar pre- and post-updated hs-cTn ADP implementation (pre 13.0%, post 15.4% (P = 0.43).
Implementation of hs-cTn supported by an updated ADP was associated with a lower rate of stress testing and coronary CT angiogram.
在因疑似急性心肌梗死（MI）而到急诊科就诊的患者中，通常使用心脏肌钙蛋白（cTn）检测来检测急性心肌损伤。加速诊断方案（ADPs）指导临床医生将 cTn 结果与其他临床信息相结合，以决定是否进行进一步的诊断性检查。
确定在将高敏（hs-cTn）检测应用于更新后的 ADP 后，急诊科胸痛患者在 cTn 检测后进行应激试验或冠状动脉 CT 血管造影的频率和阳性率的变化。
我们使用电子健康记录，在 hs-cTn 检测转换前后各 1 年，检查了与一个综合学术健康系统相关的五个急诊科的胸痛就诊情况。结果包括应激试验或冠状动脉成像的频率、进行额外检查的 ADP 符合率，以及诊断阳性率（阳性检查与总检查的比值）。
共有 7564 例胸痛患者就诊，其中 3665 例在 hs-cTn 检测前，3899 例在 hs-cTn 检测后。在使用 hs-cTn 的更新 ADP 后，862 例（每 100 例患者就诊 23.5 例）就诊导致后续检查，而在 hs-cTn 检测前，1085 例（每 100 例患者就诊 27.8 例）就诊导致后续检查（P < 0.001）。在接受检查的患者中，符合方案的比例从 80.9%降至 46.5%（P < 0.001），但检查阳性率从 24.5%上升至 29.2%（P = 0.07）。在不符合 ADP 指导的检查中，检测阳性率在 hs-cTn ADP 更新前后相似（更新前 13.0%，更新后 15.4%（P = 0.43））。
hs-cTn 的应用支持更新的 ADP，与应激试验和冠状动脉 CT 血管造影的使用频率较低相关。
