Selecting patients with non-ST-elevation acute coronary syndrome for coronary angiography: a nationwide clinical vignette study in the Netherlands.
Selecting patients with non-ST-elevation acute coronary syndrome for coronary angiography: a nationwide clinical vignette study in the Netherlands.
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为冠状动脉造影术的非ST急性急性冠状动脉综合征的患者选择：荷兰的全国临床小插图研究。
DOI：
10.1136/bmjopen-2016-011213
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发表时间：
2017-01-19
期刊：
影响因子：
2.9
通讯作者：
Wagner C
中科院分区：
文献类型：
--
作者：
Engel J;Poldervaart JM;van der Wulp I;Reitsma JB;de Bruijne MC;Bunge JJ;Cramer MJ;Tietge WJ;Uijlings R;Wagner C
心脏指南建议，对非 ST 段抬高急性冠状动脉综合征 (NST-ACS) 患者进行冠状动脉造影 (CA) 的决定应基于多种因素。然而，尚不清楚心脏病专家在决策时如何权衡这些因素。目的是调查不同临床特征（包括来自风险评分的信息）在荷兰心脏病专家对疑似 NST-ACS 患者进行 CA 决策时的重要性。包含临床小插曲的基于网络的调查。我们联系了注册的荷兰心脏病专家来完成这项调查，其中要求他们表明是否会针对描述 7 个临床因素的 8 个小插图进行 CA：年龄、肾功能、已知的冠状动脉疾病、持续性胸痛、是否存在危险因素、心电图结果和肌钙蛋白水平。心脏病专家被分为两组：第一组收到“没有”存在风险评分的小插图，而第二组则完成“有”存在风险评分的小插图。共有 946 名心脏病专家中有 129 名做出了回应。在两组中，肌钙蛋白水平升高和典型的缺血性变化 (p<0.001) 使得心脏病专家决定更频繁地进行 CA。严重的肾功能障碍 (p<0.001) 使心脏病专家在决定 CA 时更加犹豫。年龄和风险评分无法独立评估，因为这些因素密切相关。例如，对这些因素进行综合检查后发现，与中等风险评分的年轻患者相比，心脏病专家对高风险评分的老年患者进行 CA 更加犹豫。当决定对疑似 NST-ACS 的患者进行院内 CA（患者入院后≤72 小时）时，心脏病专家往往主要依赖肌钙蛋白水平、心电图变化和肾功能。未来的研究应该集中于为什么在严重肾功能不全的患者和高危评分的老年患者中较少推荐进行 CA。此外，还应进一步研究年龄和风险评分对决策的影响。
Cardiac guidelines recommend that the decision to perform coronary angiography (CA) in patients with Non-ST-Elevation Acute Coronary Syndrome (NST-ACS) is based on multiple factors. It is, however, unknown how cardiologists weigh these factors in their decision-making. The aim was to investigate the importance of different clinical characteristics, including information derived from risk scores, in the decision-making of Dutch cardiologists regarding performing CA in patients with suspected NST-ACS. A web-based survey containing clinical vignettes. Registered Dutch cardiologists were approached to complete the survey, in which they were asked to indicate whether they would perform CA for 8 vignettes describing 7 clinical factors: age, renal function, known coronary artery disease, persistent chest pain, presence of risk factors, ECG findings and troponin levels. Cardiologists were divided into two groups: group 1 received vignettes ‘without’ a risk score present, while group 2 completed vignettes ‘with’ a risk score present. 129 (of 946) cardiologists responded. In both groups, elevated troponin levels and typical ischaemic changes (p<0.001) made cardiologists decide more often to perform CA. Severe renal dysfunction (p<0.001) made cardiologists more hesitant to decide on CA. Age and risk score could not be assessed independently, as these factors were strongly associated. Inspecting the factors together showed, for example, that cardiologists were more hesitant to perform CA in elderly patients with high-risk scores than in younger patients with intermediate risk scores. When deciding to perform in-hospital CA (≤72 hours after patient admission) in patients with suspected NST-ACS, cardiologists tend to rely mostly on troponin levels, ECG changes and renal function. Future research should focus on why CA is less often recommended in patients with severe renal dysfunction, and in elderly patients with high-risk scores. In addition, the impact of age and risk score on decision-making should be further investigated.