A 2-Hour Diagnostic Protocol for Possible Cardiac Chest Pain in the Emergency Department A Randomized Clinical Trial
A 2-Hour Diagnostic Protocol for Possible Cardiac Chest Pain in the Emergency Department A Randomized Clinical Trial
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DOI：
10.1001/jamainternmed.2013.11362
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发表时间：
2014-01-01
影响因子：
39
通讯作者：
Richards, A. Mark
中科院分区：
文献类型：
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作者：
Than, Martin;Aldous, Sally;Richards, A. Mark
重要的胸痛患者代表着很高的医疗保健负担，但有可能确定一组短期不良心脏事件风险较低的适合早期出院的患者。目的比较快速诊断路径和标准护理诊断路径在常规临床实践环境下评估潜在心源性胸痛患者的有效性。设计、设置和参与者在一家综合性大学和三级医院进行了一项单中心、随机、平行分组的盲法结果评估试验。参与者包括患有急性冠脉综合征的急性胸痛的成年人，主治医生计划对他们进行进一步的观察和肌钙蛋白测试。患者招募发生在2010年10月11日至2012年7月4日，有30天的随访。干预采用加速诊断方案的实验路径(心肌梗死溶栓评分，0；心电图；结果观察组270例中有52例在6小时内出院，对照组272例中有30例在6小时内出院(优势比为19.3%比11.0%；优势比为1.92；95%可信区间为1.18-3.13；P=0.008)。对照组患者在6小时内出院所需时间为20小时，与试验组相同。在实验组中，另有35名患者(12.9%)被归类为低风险但住进住院病房进行心脏检查。35例患者在住院评估后均未被诊断为急性冠脉综合征。结论在实验路径中使用加速诊断方案的相关性使胸痛患者提前出院的比例几乎翻了一番。临床医生可以在不到6小时的时间内将大约1/5的胸痛患者出院到门诊随访监测。这种诊断策略可以很容易地在其他中心复制，因为不需要额外的资源。
IMPORTANCE Patients with chest pain represent a high health care burden, but it may be possible to identify a patient group with a low short-term risk of adverse cardiac events who are suitable for early discharge.OBJECTIVE To compare the effectiveness of a rapid diagnostic pathway with a standard-care diagnostic pathway for the assessment of patients with possible cardiac chest pain in a usual clinical practice setting.DESIGN, SETTING, AND PARTICIPANTS A single-center, randomized parallel-group trial with blinded outcome assessments was conducted in an academic general and tertiary hospital. Participants included adults with acute chest pain consistent with acute coronary syndrome for whom the attending physician planned further observation and troponin testing. Patient recruitment occurred from October 11, 2010, to July 4, 2012, with a 30-day follow-up.INTERVENTIONS An experimental pathway using an accelerated diagnostic protocol (Thrombolysis in Myocardial Infarction score, 0; electrocardiography; and 0- and 2-hour troponin tests) or a standard-care pathway (troponin test on arrival at hospital, prolonged observation, and a second troponin test 6-12 hours after onset of pain) serving as the control.MAIN OUTCOMES AND MEASURES Discharge from the hospital within 6 hours without a major adverse cardiac event occurring within 30 days.RESULTS Fifty-two of 270 patients in the experimental group were successfully discharged within 6 hours compared with 30 of 272 patients in the control group (19.3% vs 11.0%; odds ratio, 1.92; 95% CI, 1.18-3.13; P = .008). It required 20 hours to discharge the same proportion of patients from the control group as achieved in the experimental group within 6 hours. In the experimental group, 35 additional patients (12.9%) were classified as low risk but admitted to an inpatient ward for cardiac investigation. None of the 35 patients received a diagnosis of acute coronary syndrome after inpatient evaluation.CONCLUSIONS AND RELEVANCE Using the accelerated diagnostic protocol in the experimental pathway almost doubled the proportion of patients with chest pain discharged early. Clinicians could discharge approximately 1 of 5 patients with chest pain to outpatient follow-up monitoring in less than 6 hours. This diagnostic strategy could be easily replicated in other centers because no extra resources are required.