Laudon D A, Vukov L F, Breen J F, Rumberger J A, Wollan P C, Sheedy P F
Division of Emergency Medical Services and Internal Medicine, Mayo Clinic and Mayo Foundation, Rochester, MN 55905, USA.
Ann Emerg Med. 1999 Jan;33(1):15-21. doi: 10.1016/s0196-0644(99)70412-9.
We sought to determine whether electron-beam computed tomography (EBCT) could be used as a triage tool in the emergency department for patients with angina-like chest pain, no known history of coronary disease, normal or indeterminate ECG findings, and normal initial cardiac enzyme concentrations.
We conducted a prospective observational study of 105 patients admitted between December 1995 and October 1997 to the ED of a large tertiary care hospital with 70,000 annual ED visits. The study group was comprised of women aged 40 to 65 years and men aged 30 to 55 years who presented with angina-like chest pain requiring admission to the hospital or chest pain observation unit. All patients underwent EBCT of the coronary arteries, along with other cardiac testing as deemed necessary by staff physicians.
Of the 105 patients, 100 underwent other cardiac testing during hospitalization. Evaluation included treadmill exercise testing in 58, coronary angiography in 25, radionuclide stress testing in 19, and echocardiography in 11. Results of EBCT and cardiac testing were negative for both in 53 patients (53%), positive for both in 14 (14%), positive for tomography and negative for cardiac testing in 32 (32%), and negative for tomography and positive for cardiac testing in only 1 patient. This positive test result, on a treadmill exercise test, was ruled a false positive by an independent staff cardiologist. Two other female patients with normal exercise sestamibi or coronary angiography and EBCT findings also had false-positive treadmill exercise results. The sensitivity of EBCT was 100% (95% confidence interval, 77% to 100%), with a negative predictive value of 100% (95% confidence interval, 94% to 100%). Specificity was 63% (95% confidence interval, 54% to 75%).
EBCT is a rapid and efficient screening tool for patients admitted to the ED with angina-like chest pain, normal cardiac enzyme concentrations, indeterminate ECG findings, and no history of coronary artery disease. Our study suggests that patients with normal initial cardiac enzyme concentrations, normal or indeterminate ECG findings, and negative results on EBCT may be safely discharged from the ED without further testing or observation. Larger studies are required to confirm this conclusion.
我们试图确定电子束计算机断层扫描（EBCT）能否作为急诊科对有类似心绞痛胸痛症状、无已知冠心病史、心电图结果正常或不确定且初始心肌酶浓度正常的患者进行分流的工具。
我们对1995年12月至1997年10月期间入住一家年急诊科就诊量达70000人次的大型三级医院急诊科的105例患者进行了一项前瞻性观察研究。研究组由年龄在40至65岁的女性和30至55岁的男性组成，他们因类似心绞痛的胸痛症状而需要住院或进入胸痛观察病房。所有患者均接受了冠状动脉的EBCT检查以及工作人员医生认为必要的其他心脏检查。
105例患者中，100例在住院期间接受了其他心脏检查。评估包括58例进行了平板运动试验，25例进行了冠状动脉造影，19例进行了放射性核素负荷试验，11例进行了超声心动图检查。EBCT和心脏检查结果均为阴性的有53例患者（53%），两者均为阳性的有14例（14%），断层扫描阳性而心脏检查阴性的有32例（32%），断层扫描阴性而心脏检查阳性的仅1例患者。该例平板运动试验的阳性结果被一位独立的工作人员心脏病专家判定为假阳性。另外两名运动心肌显像或冠状动脉造影及EBCT结果正常的女性患者平板运动试验结果也为假阳性。EBCT的敏感性为100%（95%置信区间，77%至100%），阴性预测值为100%（95%置信区间，94%至100%）。特异性为63%（95%置信区间，54%至75%）。
对于入住急诊科有类似心绞痛胸痛症状、心肌酶浓度正常、心电图结果不确定且无冠状动脉疾病史的患者，EBCT是一种快速有效的筛查工具。我们的研究表明，初始心肌酶浓度正常、心电图结果正常或不确定且EBCT结果为阴性的患者可安全地从急诊科出院，无需进一步检查或观察。需要更大规模的研究来证实这一结论。
