Gomez M A, Anderson J L, Karagounis L A, Muhlestein J B, Mooers F B
LDS Hospital, Salt Lake City, Utah 84143, USA.
J Am Coll Cardiol. 1996 Jul;28(1):25-33. doi: 10.1016/0735-1097(96)00093-9.
We tested the hypothesis that an emergency department-based protocol for rapidly ruling out myocardial ischemia would reduce hospital time and expense but maintain diagnostic accuracy.
Patients with a missed diagnosis of myocardial infarction have a high mortality rate; however, providing routine hospital care to low risk patients may not be time- or cost-effective.
One hundred low risk patients were entered into the study and randomized either to an emergency department-based rapid rule-out protocol (n = 50) or to routine hospital care (n = 50). Patients receiving routine care were managed by their attending physicians. The rapid protocol included serum enzyme testing at 0, 3, 6 and 9h, serial electrocardiograms with continuous ST segment monitoring and, if results were negative, a predischarge graded exercise test. Study patients were also compared with 160 historical control subjects.
Myocardial infarction or unstable angina occurred in 6% of patients within 30 days; no diagnoses were missed. By intention to treat analysis (n = 50 in each group), the hospital stay was shorter and charges were lower with the rapid protocol than with routine care (p = 0.001). Among patients in whom ischemia was ruled out, those assigned to the rapid protocol had a shorter hospital stay (median 11.9 vs. 22.8 h, p = 0.0001) and lower initial ($893 vs $1,349, p = 0.0001) and 30-day ($898 vs. $1,522, p = 0.0001) hospital charges than did patients given routine care. In historical control subjects, the hospital stay was longer (median 34.5 h, p = 0.001 vs. either group) and charges greater (median $2,063, p = 0.001, vs rapid protocol, p = 0.02, vs. routine care group).
In low risk patients who present to the emergency department with chest pain, the rapid protocol ruled out myocardial infarction and unstable angina more quickly and cost-effectively than did routine hospital care.
我们检验了这样一种假设，即基于急诊科的快速排除心肌缺血方案可减少住院时间和费用，同时保持诊断准确性。
心肌梗死漏诊患者死亡率很高；然而，为低风险患者提供常规住院治疗可能在时间或成本上并不划算。
100例低风险患者纳入本研究，并随机分为基于急诊科的快速排除方案组（n = 50）或常规住院治疗组（n = 50）。接受常规治疗的患者由其主治医师进行管理。快速方案包括在0、3、6和9小时进行血清酶检测，连续进行ST段监测的系列心电图检查，若结果为阴性，则在出院前进行分级运动试验。研究患者还与160例历史对照受试者进行了比较。
30天内6%的患者发生心肌梗死或不稳定型心绞痛；无漏诊情况。按照意向性分析（每组n = 50），与常规治疗相比，快速方案组的住院时间更短，费用更低（p = 0.001）。在排除缺血的患者中，分配到快速方案组的患者住院时间更短（中位数11.9小时对22.8小时，p = 0.0001），初始住院费用（893美元对1349美元，p = 0.0001）和30天住院费用（898美元对1522美元，p = 0.0001）均低于接受常规治疗的患者。在历史对照受试者中，住院时间更长（中位数34.5小时，与两组相比p = 0.001），费用更高（中位数2063美元，与快速方案组相比p = 0.001，与常规治疗组相比p = 0.02）。
对于因胸痛就诊于急诊科的低风险患者，快速方案比常规住院治疗能更快且更经济有效地排除心肌梗死和不稳定型心绞痛。
