Sanz G, Betriu A, Oller G, Matas M, Magriñá J, Paré C, Roig E, Heras M, Azqueta M, Bosch X
Cardiac Unit, Hospital Clínic, University of Barcelona, Spain.
J Am Coll Cardiol. 1993 Dec;22(7):1795-801. doi: 10.1016/0735-1097(93)90759-t.
The purpose of this study was to analyze the feasibility of early discharge (4 days) after acute myocardial infarction in patients not receiving thrombolytic therapy by first identifying predictors of short-term prognosis and then testing the derived risk profile in an independent cohort of patients.
Previous studies have shown that early discharge after acute myocardial infarction is possible. However, physicians are reluctant to shorten the standard 7- to 10-day hospital stay, presumably because of difficulty in selecting low risk patients.
From January 1985 to November 1986, 358 patients with acute myocardial infarction who did not receive thrombolytic therapy were screened. Those with a Q-wave infarction showing no complications on day 4 were considered candidates for early discharge and were transferred to the ward for a mean of 12 days. During this period, we looked for any event (cardiac or noncardiac) that would have prompted readmission if the patient had been previously discharged. Univariate and multiple regression analysis were performed to identify predictors of these events among 25 baseline variables. The derived risk profile was tested in an independent validation cohort.
One hundred five (29.3%) of the 358 patients were free of symptoms on day 4, and 29 (27.6%) had at least one cardiac event, including four deaths and one reinfarction. Multivariate analysis selected diabetes, ejection fraction < 40% and age as independent predictors of events. Using the risk profile, 18 (13.2%) of the 136 validation cohort patients were categorized as low risk, and only 1 of them had a major event (progressive angina). Sensitivity for the risk profile was high (91%), but specificity was low (34%).
The use of simple clinical variables may allow the safe reduction of hospital stay after infarction in selected patients. However because the proportion of candidates for early discharge is small (12.6%), it seems unlikely that the current policies on length of hospital stay will change in the near future.
本研究的目的是通过首先确定短期预后的预测因素，然后在一个独立的患者队列中测试所推导的风险概况，来分析未接受溶栓治疗的急性心肌梗死患者早期出院（4天）的可行性。
先前的研究表明，急性心肌梗死后早期出院是可行的。然而，医生们不愿意缩短标准的7至10天住院时间，大概是因为难以选择低风险患者。
从1985年1月至1986年11月，对358例未接受溶栓治疗的急性心肌梗死患者进行了筛查。那些在第4天显示无并发症的Q波梗死患者被视为早期出院的候选人，并被转至病房平均12天。在此期间，我们寻找任何如果患者先前已出院就会促使再次入院的事件（心脏或非心脏事件）。对25个基线变量进行单因素和多因素回归分析，以确定这些事件的预测因素。在所推导的风险概况在一个独立的验证队列中进行了测试。
358例患者中有105例（29.3%）在第4天无症状，29例（27.6%）发生至少一次心脏事件，包括4例死亡和1例再梗死。多因素分析选择糖尿病、射血分数<40%和年龄作为事件的独立预测因素。使用该风险概况，136例验证队列患者中有18例（13.2%）被归类为低风险，其中只有1例发生了重大事件（进行性心绞痛）。该风险概况的敏感性较高（91%），但特异性较低（34%）。
使用简单的临床变量可能允许在选定的患者中安全缩短梗死后的住院时间。然而，由于早期出院候选人的比例较小（12.6%），近期内现行的住院时间政策似乎不太可能改变。
