BMJ2014-05-21 4:36 PM

疑似心源性胸痛的曼彻斯特急性冠脉综合征(MACS)决策规则:推导和外部验证 The Manchester Acute Coronary Syndromes (MACS) decision rule for suspected cardiac chest pain: derivation and external validation

论文摘要
Abstract

研究目标 
我们目标于推导和验证急诊科(ED)疑似心源性胸痛的临床决策规则(CDR)。结合首次得到的信息,这一CDR能够有效按风险分层筛选患者并立即确定:(A)保障患者安全的前提下避免住院治疗;(B)使得高危患者合理利用资源。 
Objective 
We aimed to derive and validate a clinical decision rule (CDR) for suspected cardiac chest pain in the emergency department (ED). Incorporating information available at the time of first presentation, this CDR would effectively risk-stratify patients and immediately identify: (A) patients for whom hospitalisation may be safely avoided; and (B) high-risk patients, facilitating judicious use of resources.

研究方法 
在异构中心的两个连续性前瞻性观察队列研究中,我们包含了疑似心源性胸痛的ED患者,并且记录了临床特点并在报到时抽取了血样。所得的主要结果是30天内的主要不良心脏事例(MACE)(死亡,流行或事故性急性心肌梗死,冠状动脉血运重建或新冠状动脉狭窄> 50%)。该CDR由Logistic回归方法所推导,并将可靠(κ> 0.6)单变量预测因素(P<0.05)列入考虑内。
Methods 
In two sequential prospective observational cohort studies at heterogeneous centres, we included ED patients with suspected cardiac chest pain. We recorded clinical features and drew blood on arrival. The primary outcome was major adverse cardiac events (MACE) (death, prevalent or incident acute myocardial infarction, coronary revascularisation or new coronary stenosis >50%) within 30 days. The CDR was derived by logistic regression, considering reliable (κ>0.6) univariate predictors (p<0.05) for inclusion.

研究结果 
在(N=698)推导研究中,我们得出了包括8个变量的CDR(高灵敏度肌钙蛋白T;心脏型脂肪酸结合蛋白;心电图缺血;发汗观察;呕吐;右手臂/肩膀的疼痛放射;恶化型心绞痛;低血压),其中的C-统计量为0.95(95%CI为0.93〜0.97),这意味着近乎完美的诊断性能。 在(N=463)外部验证中,CDR判定27.0% 的患者为“极低风险”并可以潜在避免ED治疗。这些患者无一发生常见急性心肌梗死且只有其中的1.6%患得MACE(n=2时,两者冠状动脉狭窄无血运重建)。9.9%的患者被归为'高风险',且其中的95.7%患得MACE。 
Results 
In the derivation study (n=698) we derived a CDR including eight variables (high sensitivity troponin T; heart-type fatty acid binding protein; ECG ischaemia; diaphoresis observed; vomiting; pain radiation to right arm/shoulder; worsening angina; hypotension), which had a C-statistic of 0.95 (95% CI 0.93 to 0.97) implying near perfect diagnostic performance. On external validation (n=463) the CDR identified 27.0% of patients as ‘very low risk’ and potentially suitable for discharge from the ED. 0.0% of these patients had prevalent acute myocardial infarction and 1.6% developed MACE (n=2; both coronary stenoses without revascularisation). 9.9% of patients were classified as ‘high-risk’, 95.7% of whom developed MACE.

研究结论 
曼彻斯特急性冠脉综合征(MACS)规则能潜在安全地减少不必要的住院治疗并能促进对高度依赖资源的合理使用。
Conclusions
The Manchester Acute Coronary Syndromes (MACS) rule has the potential to safely reduce unnecessary hospital admissions and facilitate judicious use of high dependency resources.

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论文摘要Abstract研究目标 我们目标于推导和验证急诊科(ED)疑似心源性胸痛的临床决策规则(CDR)。结合首次得到的信息,这一CDR能够有效按风险分层筛选患者并立即确定:(A)保障患者安全的前提下避免住院治疗;(B)使得高危患者合理利用资源。 Objective We aimed to deri

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