Myocardial perfusion imaging for evaluation and triage of patients with suspected acute cardiac ischemia - A randomized controlled trial
Myocardial perfusion imaging for evaluation and triage of patients with suspected acute cardiac ischemia - A randomized controlled trial
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DOI：
10.1001/jama.288.21.2693
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发表时间：
2002-12-04
影响因子：
120.7
通讯作者：
Selker, HP
中科院分区：
文献类型：
--
作者：
Udelson, JE;Beshansky, JR;Selker, HP
背景急性心肌灌注成像在急诊科（艾德）胸痛患者中的观察性研究表明，急性心肌缺血具有高灵敏度和阴性预测值，目的探讨急性静息灌注显像（ARI）是否可用于艾德（ED）的评估，以评估早期无心电图（ECG）但疑似急性缺血的患者的ED急性缺血诊断的变化改善了最初艾德分类的临床决策。设计、设置和患者前瞻性，1997年7月至1999年5月在7个学术医疗中心和社区医院进行的一项随机对照试验，纳入了2475例成人艾德患者，这些患者有胸痛或其他提示急性心肌缺血的症状，干预患者被随机分配接受通常的艾德评估策略（n=1260）或补充有来自急性静息心肌灌注成像的结果的通常策略，所述急性静息心肌灌注成像使用注射20至30 mCi的Tc-99 m sestamibi的单光子发射计算机断层扫描（n=1215），由当地医生进行真实的实时解读，并将结果提供给艾德医生，以纳入临床决策。主要结果测量分诊决定的适当性，无论是入院/观察还是从艾德直接出院。（即急性心肌梗死[MI]或不稳定型心绞痛; n = 329），在接受标准评估的患者和接受sestamibi扫描补充评估的患者之间，艾德分诊决策没有差异。急性心肌梗死患者（n = 56）中，97% vs 96%住院（相对风险[RR]，1.00; 95%置信区间[CI]，0.89-1.12），不稳定型心绞痛患者（n =273）中，83% vs 81%住院（RR，0.98; 95% CI，0.87-1.10）。然而，在无急性心肌缺血的患者中（n=2146），常规治疗的住院率为52%，而使用Sestamibi成像的住院率为42%（RR，0.84; 95%CI，0.77-0.92）。结论Sestamibi灌注成像可提高艾德对有急性心肌缺血症状但初始ECG无明显异常的患者的分诊决策。在这项研究中，减少了非急性缺血患者不必要的住院治疗，而没有减少急性缺血患者的适当入院。
Context Observational studies of acute myocardial perfusion imaging in emergency department (ED) patients with chest pain have suggested high sensitivity and negative predictive value for acute cardiac ischemia, but use of this method has not been prospectively tested.Objective To assess whether incorporating acute resting perfusion imaging into an ED evaluation strategy for patients with suspected acute ischemia but no initial electrocardiogram (ECG) changes diagnostic of acute ischemia improves clinical decision making for initial ED triage.Design, Setting, and Patients Prospective, randomized controlled trial conducted at 7 academic medical centers and community hospitals between July 1997 and May 1999 among 2475 adult ED patients with chest pain or other symptoms suggestive of acute cardiac ischemia and with normal or nondiagnostic initial ECG results.Intervention Patients were randomly assigned to receive either the usual ED evaluation strategy (n=1260) or the usual strategy supplemented with results from acute resting myocardial perfusion imaging using single-photon emission computed tomography with injection of 20 to 30 mCi of Tc-99m sestamibi (n=1215), interpreted in real time by local staff physicians and with results provided to the ED physician for incorporation into clinical decision making.Main Outcome Measure Appropriateness of triage decision either to admit to hospital/observation or to discharge directly home from the ED.Results Among patients with acute cardiac ischemia (ie, acute myocardial infarction [MI] or unstable angina; n = 329), there were no differences in ED triage decisions between those receiving standard evaluation and those whose evaluation was supplemented by a sestamibi scan. Among patients with acute MI (n = 56), 97% vs 96% were hospitalized (relative risk [RR], 1.00; 95% confidence interval [CI], 0.89-1.12), and among those with unstable angina (n =273), 83% vs 81% were hospitalized (RR, 0.98; 95% Cl, 0.87-1.10). However, among patients without acute cardiac ischemia (n=2146), hospitalization was 52% with usual care vs 42% with sestamibi imaging (RR, 0.84; 95% Cl, 0.77-0.92).Conclusions Sestamibi perfusion imaging improves ED triage decision making for patients with symptoms suggestive of acute cardiac ischemia without obvious abnormalities on initial ECG. In this study, unnecessary hospitalizations were reduced among patients without acute ischemia, without reducing appropriate admission for patients with acute ischemia.