Testing of Low-Risk Patients Presenting to the Emergency Department With Chest Pain A Scientific Statement From the American Heart Association
Testing of Low-Risk Patients Presenting to the Emergency Department With Chest Pain A Scientific Statement From the American Heart Association
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DOI：
10.1161/cir.0b013e3181ec61df
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发表时间：
2010-10-26
期刊：
影响因子：
37.8
通讯作者：
Thompson, Paul D.
中科院分区：
文献类型：
--
作者：
Amsterdam, Ezra A.;Kirk, J. Douglas;Thompson, Paul D.
急诊科低风险患者的管理是一个常见且具有挑战性的临床问题，每年需要800万急诊科就诊。虽然这些患者中的大多数没有危及生命的情况，但临床医生必须区分那些需要紧急治疗严重问题的患者和那些不需要入院的良性实体。急性冠状动脉综合征患者从急诊室意外出院与死亡率和责任增加相关，而无严重疾病的患者不适当的入院既无指征也无成本效益。临床判断和基本的临床工具（病史、体格检查和心电图）仍然是应对这一挑战和早期识别低风险胸痛患者的主要手段。此外，成熟和更新的诊断方法扩展了临床医生在这种情况下的诊断能力。出现胸痛的低风险患者越来越多地在胸痛单元中进行管理，其中执行加速诊断方案，包括连续心电图和心脏损伤标记物以排除急性冠状动脉综合征。阴性结果的患者通常完成加速诊断方案，并进行确认试验以排除缺血。这通常是运动平板试验或心脏成像研究（如果运动平板试验不适用）。静息心肌灌注成像在这种情况下发挥了重要作用。计算机断层扫描冠状动脉造影术也显示出在这种情况下的承诺。阴性加速诊断方案评价允许出院，而阳性结果的患者则被收治。这种方法已被发现是安全的，准确的，并具有成本效益的低风险患者胸痛。（循环。2010;122：1756-1776.）
The management of low-risk patients presenting to emergency departments is a common and challenging clinical problem entailing 8 million emergency department visits annually. Although a majority of these patients do not have a life-threatening condition, the clinician must distinguish between those who require urgent treatment of a serious problem and those with more benign entities who do not require admission. Inadvertent discharge of patients with acute coronary syndrome from the emergency department is associated with increased mortality and liability, whereas inappropriate admission of patients without serious disease is neither indicated nor cost-effective. Clinical judgment and basic clinical tools (history, physical examination, and electrocardiogram) remain primary in meeting this challenge and affording early identification of low-risk patients with chest pain. Additionally, established and newer diagnostic methods have extended clinicians' diagnostic capacity in this setting. Low-risk patients presenting with chest pain are increasingly managed in chest pain units in which accelerated diagnostic protocols are performed, comprising serial electrocardiograms and cardiac injury markers to exclude acute coronary syndrome. Patients with negative findings usually complete the accelerated diagnostic protocol with a confirmatory test to exclude ischemia. This is typically an exercise treadmill test or a cardiac imaging study if the exercise treadmill test is not applicable. Rest myocardial perfusion imaging has assumed an important role in this setting. Computed tomography coronary angiography has also shown promise in this setting. A negative accelerated diagnostic protocol evaluation allows discharge, whereas patients with positive findings are admitted. This approach has been found to be safe, accurate, and cost-effective in low-risk patients presenting with chest pain. (Circulation. 2010;122:1756-1776.)