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 该提案的最终目标是改善急诊科（艾德）评估后的结果， 疑似急性冠脉综合征（ACS）。ACS包括急性心肌梗死（AMI）和不稳定性心肌梗死（AMI）。 心绞痛，并且是世界范围内死亡率和发病率的主要原因。疑似ACS是第二大 是美国艾德来访的常见原因，每年接待超过700万人次。艾德占少数（13 胸痛就诊与ACS有关，诊断具有很高的临床和医学法律风险。 为了最大限度地减少ACS的漏诊，美国心脏协会建议进行无创心脏检查（例如， 心电图[ECG]、负荷超声心动图[echo]、负荷心肌灌注[MP]或冠状动脉 计算机断层扫描血管造影[CCTA]）。 此外，疑似ACS的患者通常被送入住院病床或观察室， 促进早期非侵入性测试，并降低缺血性心脏危险并发症的风险 疾病疑似ACS的评估是美国短期住院（<48小时）和观察的首要原因 每年的住院费用为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益 患者目前使用的早期非侵入性检查增加了侵入性冠状动脉造影的发生率， 血运重建而不降低AMI风险。低风险患者住院的潜在益处 似乎是边缘性的（入院期间心脏事件发生率<0.2%）。各种各样的非侵入性 检测（顶部和底部四分位数医院之间的差异为6倍）和住院（顶部和底部四分位数医院之间的差异为7倍） 和底部四分之一医院）的疑似ACS建议普遍的最佳方法的不确定性。 使用综合卫生系统中约170，000例患者就诊的前瞻性观察数据，我们 将评估五种早期诊断（负荷ECG、负荷超声、负荷MP、CCTA或无创检查）， 三种处置（住院、观察、出院）策略： 目标1.比较疑似ACS的早期诊断检测策略的30天结局 目标2.比较疑似ACS处置策略的30天结局 目标3.评估检测前风险是否影响早期诊断和 疑似ACS的处置策略 目标4。疑似ACS早期诊断和处置策略的成本-效果比较 这些目标解决了任何疑似ACS评估的基本问题：1。如果需要什么测试？ 2.录取是否有利？3.患者预测试风险如何改变管理？目标4将为政策提供信息 制造商和付款人关于不同策略的比较价值。