Acute Coronary Syndrome Screening and Diagnostic Practice Variation.
Acute Coronary Syndrome Screening and Diagnostic Practice Variation.
复制标题
急性冠状动脉综合征筛查和诊断实践变化。
DOI：
10.1111/acem.13184
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发表时间：
2017
期刊：
影响因子：
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通讯作者：
EDOperationsStudyGroup2015
中科院分区：
文献类型：
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作者：
Yiadom,MaameYaaAB;Liu,Xulei;McWade,ConorM;Liu,Dandan;Storrow,AlanB;EDOperationsStudyGroup2015
背景在缺乏指导急诊科（艾德）筛查和诊断临床实践的现有急性冠脉综合征（ACS）指南的情况下，在艾德机构中存在不同的筛查和诊断临床实践。这种做法的多样性可能是有道理的。了解变异性可能会发现机会，更一致的practice.MethodsThis是一个横截面的临床实践流行病学研究的艾德作为单位的分析表征变异性ACS评价在62个不同的ED。我们探讨了筛查和诊断实践的三个领域：1）ED用于识别患者进行早期心电图（ECG）以诊断ST段抬高型心肌梗死（STEMI）的标准存在差异，2）用于诊断非ST段抬高型心肌梗死（NSTEMI）的肌钙蛋白生物标志物和正式肌钙蛋白前风险分层不一致，和3）在使用非侵入性测试（NIVT）的变化，以确定阻塞性冠状动脉疾病或检测诱导ischemia.ResultsWe发现，85%的ED利用一个正式的分诊协议筛选患者的早期心电图诊断STEMI。其中，17%使用胸痛作为唯一标准。对于NSTEMI的诊断，58%的患者使用间隔≥4小时的第二次肌钙蛋白检测，34%的患者在肌钙蛋白检测前进行常规风险分层。对于非梗死性缺血的诊断，在艾德访视期间进行NIVT的患者百分比中位数为5%。住院（观察或入院）的NIVT患者的中位百分比为61%。66%的ED使用冠状动脉CT血管造影术。运动平板试验是最常报告的一线NIVT（42%）。
BackgroundIn the absence of the existing acute coronary syndrome (ACS) guidelines directing the clinical practice implementation of emergency department (ED) screening and diagnosis, there is variable screening and diagnostic clinical practice across ED facilities. This practice diversity may be warranted. Understanding the variability may identify opportunities for more consistent practice.MethodsThis is a cross‐sectional clinical practice epidemiology study with the ED as the unit of analysis characterizing variability in the ACS evaluation across 62 diverse EDs. We explored three domains of screening and diagnostic practice: 1) variability in criteria used by EDs to identify patients for an early electrocardiogram (ECG) to diagnose ST‐elevation myocardial infarction (STEMI), 2) nonuniform troponin biomarker and formalized pre‐troponin risk stratification use for the diagnosis of non‐ST‐elevation myocardial infarction (NSTEMI), and 3) variation in the use of noninvasive testing (NIVT) to identify obstructive coronary artery disease or detect inducible ischemia.ResultsWe found that 85% of EDs utilize a formal triage protocol to screen patients for an early ECG to diagnose STEMI. Of these, 17% use chest pain as the sole criteria. For the diagnosis of NSTEMI, 58% use intervals ≥4 hours for a second troponin and 34% routinely risk stratify before troponin testing. For the diagnosis of noninfarction ischemia, the median percentage of patients who have NIVT performed during their ED visit is 5%. The median percentage of patients referred for NIVT in hospital (observation or admission) is 61%. Coronary CT angiography is used in 66% of EDs. Exercise treadmill testing is the most frequently reported first‐line NIVT (42%).ConclusionOur results suggest highly variable ACS screening and clinical practice.