Comparative Effectiveness of Early Diagnostic and Disposition Strategies for Suspected Acute Coronary Syndrome

疑似急性冠状动脉综合征早期诊断和处置策略的比较效果

• 批准号: 9378509
• 负责人: Benjamin C Sun
• 金额: $ 81.58万
• 依托单位: OREGON HEALTH & SCIENCE UNIVERSITY
• 依托单位国家: 美国
• 财政年份: 2017
• 资助国家: 美国
• 起止时间: 2017-08-18 至 2021-05-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9378509
• 关键词: Accident and Emergency department; Acute myocardial infarction; Address; Admission activity; Affect; American Heart Association; Angiography; Arrhythmia; Beds; Biological Markers; Cardiac; Cessation of life; Chest Pain; Clinical; Clinical Data; Coronary; Coronary Angiography; Dangerousness; Data; Diagnosis; Diagnostic; Diagnostic tests; Dyes; Echocardiography; Electrocardiogram; Emergency Department evaluation; Emergency department visit; Evaluation; Event; Exclusion; Goals; Health system; Home environment; Hospital Costs; Hospitalization; Hospitals; Hour; Iatrogenesis; Injury; Inpatients; Intervention; Legal; Life; Literature; Malpractice; Minority; Modeling; Morbidity - disease rate; Myocardial Ischemia; Myocardial perfusion; Outcome; Patient risk; Patient-Focused Outcomes; Patients; Policy Maker; Prospective cohort; Radiation exposure; Reporting; Retrospective cohort; Risk; Stress; Sudden Death; Symptoms; Testing; Troponin; Uncertainty; Unstable angina; Visit; X-Ray Computed Tomography; accurate diagnosis; acute coronary syndrome; base; cardiovascular visualization; comparative; comparative effectiveness; cost; cost effectiveness; high risk; improved outcome; injured; mortality; prospective; randomized trial; standard of care; trial comparing

Project Summary The ultimate goal of this proposal is to improve outcomes after an emergency department (ED) evaluation for suspected acute coronary syndrome (ACS). ACS includes acute myocardial infarction (AMI) and unstable angina, and is the leading cause of worldwide mortality and morbidity. Suspected ACS is the second most frequent reason for U.S. ED visits and accounts for over 7 million annual encounters. The minority (13%) of ED chest pain visits are related to ACS, and diagnosis is challenging with high clinical and medico-legal stakes. To minimize missed ACS, the American Heart Association suggests non-invasive cardiac testing (e.g. stress electrocardiogram [ECG], stress echocardiogram [echo], stress myocardial perfusion [MP], or coronary computed tomography angiogram [CCTA]) within 72 hours, after serial biomarkers have excluded AMI. Furthermore, patients with suspected ACS are often admitted to an inpatient bed or observation unit to facilitate early non-invasive testing and to mitigate the risk of dangerous complications of ischemic heart disease. Evaluation of suspected ACS is the top reason for U.S. short-stay (<48 hrs) inpatient and observation admissions, and accounts for $3-10 billion in hospital costs per year. However, there is no evidence that early non-invasive testing or hospital based evaluation benefits patients. Current use of early non-invasive tests increases rates of invasive coronary angiography and revascularization without reducing AMI risk. The potential benefits of hospital admission in low-risk patients appear to be marginal (<0.2% cardiac event rate during admission). The widely varying rates of non-invasive testing (6x difference between top and bottom quartile hospitals) and hospitalization (7x difference between top and bottom quartile hospitals) for suspected ACS suggest pervasive uncertainty about the optimal approach. Using prospective observational data on ~170,000 patient encounters within an integrated health system, we will assess five early diagnostic (stress ECG, stress echo, stress MP, CCTA, or NO non-invasive testing) and three disposition (inpatient, observation, discharge) strategies: Aim 1. Compare 30-day outcomes of early diagnostic testing strategies for suspected ACS Aim 2. Compare 30-day outcomes of disposition strategies for suspected ACS Aim 3. Assess whether pre-test risk affects the comparative effectiveness of early diagnostic and disposition strategies for suspected ACS Aim 4. Compare cost-effectiveness of early diagnostic and disposition strategies for suspected ACS The Aims address questions fundamental to any evaluation for suspected ACS: 1. What test if any is needed? 2. Is admission beneficial? 3. How does patient pre-test risk modify management? Aim 4 will inform policy makers and payers about the comparative value of different strategies.

项目摘要 这项建议的最终目标是改善急诊科(ED)评估后的结果 疑似急性冠脉综合征(ACS)。急性冠脉综合征包括急性心肌梗死和不稳定 心绞痛是世界范围内死亡和发病的主要原因。疑似急性冠脉综合征是第二大 经常访问美国ED的原因，每年有超过700万次接触。ED中的少数(13%) 胸痛就诊与急性冠脉综合征有关，诊断具有挑战性，具有很高的临床和法医学风险。 为了最大限度地减少遗漏的急性冠脉综合征，美国心脏协会建议进行非侵入性心脏测试(例如应激 心电图、负荷超声心动图、负荷心肌灌注或冠状动脉 在系列生物标记物排除急性心肌梗死后72小时内)。 此外，疑似急性冠脉综合征的患者通常被送往住院病床或观察单元以 促进早期非侵入性检测，降低缺血性心脏危险并发症的风险 疾病。对疑似急性冠脉综合征的评估是美国短期住院和观察的首要原因 入院费用，每年占医院费用的30-100亿美元。 然而，没有证据表明早期非侵入性检测或基于医院的评估有好处 病人。目前早期非侵入性检查的使用增加了有创冠状动脉造影术和 血管重建术不会降低急性心肌梗死的风险。低风险患者入院治疗的潜在益处 似乎是边缘的(入院期间心脏事件发生率为0.2%)。非侵入性疾病的比率差异很大 测试(排名靠前和排名靠后的四分位医院相差6倍)和住院(排名靠前的医院相差7倍 对于疑似急性冠脉综合征的患者)，对最佳治疗方法普遍存在不确定性。 使用综合医疗系统中约170,000名患者的前瞻性观察数据，我们 将评估五种早期诊断(应激心电、应激回声、应激MP、CCTA或无创检测)和 三种处置策略(住院、观察、出院)： 目的1.比较疑似急性冠脉综合征早期诊断检测策略的30天结果 目的2.比较疑似急性冠脉综合征患者处置策略的30天结果 目的3.评估测试前风险是否影响早期诊断和 疑似急性冠脉综合征的处置策略 目的4.比较疑似急性冠脉综合征早期诊断和处置策略的成本效益 这些目标解决了对疑似急性冠脉综合征的任何评估的基本问题：1.如果需要的话，需要进行什么测试？ 2.入院是否有益？3.患者试前风险如何改变管理？目标4将通知政策 关于不同策略的比较价值的制定者和付款人。