Which diagnostic tests are most useful in a chest pain unit protocol?
Which diagnostic tests are most useful in a chest pain unit protocol?
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DOI：
10.1186/1471-227x-5-6
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发表时间：
2005-01-01
影响因子：
2.5
通讯作者：
Morris, Francis
中科院分区：
文献类型：
--
作者：
Goodacre, Steve;Locker, Thomas;Morris, Francis
背景：胸痛单元(CPU)结合心电记录、生化标记物和刺激性心脏测试，为急性未分化胸痛患者提供快速诊断评估。我们的目标是确定CPU协议中哪些元素对诊断和预测最有用。方法：北方综合医院的CPU使用2-6小时的连续心电/ST段监测，到达时和至少2小时后的CK-MB(质量)，最严重疼痛和运动平板试验后至少6小时的肌钙蛋白T。数据是在18个月的时间里从使用CPU管理的患者那里前瞻性收集的。CPU评估后出院的患者被邀请参加72小时后的随访，以进行心电图和肌钙蛋白T的测量。回顾所有患者的医院记录，以确定在接下来的六个月中发生的不良心脏事件。通过计算敏感度和特异度来评估每项试验的诊断准确性：1)伴临床心肌梗死的急性冠脉综合征(ACS)和2)伴心肌细胞坏死的ACS。结果：706例患者中，30例(4.2%)诊断为急性冠脉综合征合并心肌梗死，30例(4.2%)诊断为急性冠脉综合征合并心肌细胞坏死，32例(4.5%)发生不良心脏事件。对急性冠脉综合征合并心肌梗死和心肌细胞坏死的敏感性分别为：动态心电图/ST段监测33%和23%，CK-MB(质量分数)96%和63%，肌钙蛋白T(以0.03 ng/ml为阈值)96%和90%。唯一增加有用预后信息的检查是运动平板试验(6个月内心源性死亡、非致命性心肌梗死或心律失常的相对风险为6)。结论：在我们的方案中使用的连续心电/ST段监测，对于初始心电图正常或未诊断的患者，几乎没有增加诊断或预后价值。CK-MB(MASS)可以排除有临床心肌梗死的急性冠脉综合征，但不能排除心肌细胞坏死(定义为无心肌梗死的肌钙蛋白升高)。使用较低的肌钙蛋白T阳性阈值可提高该试验对心肌梗死和心肌坏死的敏感性。运动平板试验可预测随后的不良心脏事件。
Background: The chest pain unit (CPU) provides rapid diagnostic assessment for patients with acute, undifferentiated chest pain, using a combination of electrocardiographic (ECG) recording, biochemical markers and provocative cardiac testing. We aimed to identify which elements of a CPU protocol were most diagnostically and prognostically useful.Methods: The Northern General Hospital CPU uses 2-6 hours of serial ECG / ST segment monitoring, CK-MB(mass) on arrival and at least two hours later, troponin T at least six hours after worst pain and exercise treadmill testing. Data were prospectively collected over an eighteenmonth period from patients managed on the CPU. Patients discharged after CPU assessment were invited to attend a follow-up appointment 72 hours later for ECG and troponin T measurement. Hospital records of all patients were reviewed to identify adverse cardiac events over the subsequent six months. Diagnostic accuracy of each test was estimated by calculating sensitivity and specificity for: I) acute coronary syndrome (ACS) with clinical myocardial infarction and 2) ACS with myocyte necrosis. Prognostic value was estimated by calculating the relative risk of an adverse cardiac event following a positive result.Results: Of the 706 patients, 30 (4.2%) were diagnosed as ACS with myocardial infarction, 30 (4.2%) as ACS with myocyte necrosis, and 32 (4.5%) suffered an adverse cardiac event. Sensitivities for ACS with myocardial infarction and myocyte necrosis respectively were: serial ECG / ST segment monitoring 33% and 23%; CK-MB(mass) 96% and 63%; troponin T (using 0.03 ng/ml threshold) 96% and 90%. The only test that added useful prognostic information was exercise treadmill testing (relative risk 6 for cardiac death, non-fatal myocardial infarction or arrhythmia over six months).Conclusion: Serial ECG /ST monitoring, as used in our protocol, adds little diagnostic or prognostic value in patients with a normal or non-diagnostic initial ECG. CK-MB(mass) can rule out ACS with clinical myocardial infarction but not myocyte necrosis(defined as a troponin elevation without myocardial infarction). Using a low threshold for positivity for troponin T improves sensitivity of this test for myocardial infarction and myocardial necrosis. Exercise treadmill testing predicts subsequent adverse cardiac events.