Cavalier Joanna S, Ike John D, Chevalier Céleste, Cervantes Anissa, Karatela Maham F, Desai Katha, Patel Jerishma S, Graviss Edward A, Nguyen Duc T, De Azevedo Filho Clerio, Kim Han W, Limkakeng Alexander T, Gerardo Charles J, Borawski Joseph B, Klem Igor
Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.
Duke University Cardiovascular Magnetic Resonance Center, Durham, North Carolina, USA.
J Cardiovasc Magn Reson. 2025;27(1):101851. doi: 10.1016/j.jocmr.2025.101851. Epub 2025 Jan 28.
Patients presenting to the emergency department (ED) with chest pain often have abnormal high-sensitivity troponin (hsTn). However, only about 5% have an acute coronary syndrome. We aimed to assess the safety, feasibility, and utility of a clinical disposition protocol, including outpatient observation with stress cardiovascular magnetic resonance (CMR) in intermediate-risk patients with abnormal hsTn of unclear etiology.
Patients with abnormal hsTn and modified HEART-score ≤6 underwent CMR to inform diagnosis, risk stratification, and ED disposition. Patients were followed at 30 and 90 days for all-cause mortality, readmission for myocardial infarction, and unplanned coronary revascularization.
CMR was completed in 50 patients (64 years, 56% male) at a median of 23.2 h after presentation to the ED. CMR findings of coronary artery disease (CAD) were present in 19 (38%, 19/50) of patients, of which 13 had known CAD and 6 received a new diagnosis of CAD. In 12 (24%, 12/50) patients, cardiac noncoronary artery disease was diagnosed [cardiomyopathy (8), valvular disease (3), and myocarditis/pericarditis (1)], of which the majority (83%) (10/12) were new diagnoses. CMR was normal in 19 (38%, 19/50) patients. After CMR results were reported, the decision to admit was made in 10 (20%, 10/50) patients, while 40 (80%, 40/50) were discharged from the ED without further cardiac testing. Follow-up was completed in 96% (48/50) of patients, of which no patients experienced an adverse event.
A disposition protocol with outpatient observation and stress CMR is feasible and useful for determining the etiology of myocardial injury and risk stratification in patients presenting to the ED with chest pain, abnormal hsTn, and intermediate risk.
因胸痛就诊于急诊科（ED）的患者常常有异常的高敏肌钙蛋白（hsTn）。然而，只有约5%的患者患有急性冠状动脉综合征。我们旨在评估一种临床处置方案的安全性、可行性和实用性，该方案包括对病因不明的hsTn异常的中危患者进行门诊观察及负荷心血管磁共振（CMR）检查。
hsTn异常且改良HEART评分≤6的患者接受CMR检查，以辅助诊断、风险分层及急诊科处置。对患者进行30天和90天随访，观察全因死亡率、心肌梗死再入院率及非计划冠状动脉血运重建情况。
50例患者（年龄64岁，56%为男性）在就诊于急诊科后中位23.2小时完成了CMR检查。19例（38%，19/50）患者CMR检查发现冠状动脉疾病（CAD），其中13例已知患有CAD，6例为CAD新诊断病例。12例（24%，12/50）患者被诊断为非冠状动脉性心脏病[心肌病（8例）、瓣膜病（3例）、心肌炎/心包炎（1例）]，其中大多数（83%）（10/12）为新诊断病例。19例（38%，19/50）患者CMR检查结果正常。在报告CMR结果后，10例（20%，10/50）患者被决定收住院，而40例（80%，40/50）患者在未进行进一步心脏检查的情况下从急诊科出院。96%（48/50）的患者完成了随访，其中无患者发生不良事件。
对于因胸痛、hsTn异常且为中危而就诊于急诊科的患者，采用门诊观察及负荷CMR的处置方案对于确定心肌损伤病因及风险分层是可行且有用的。
