生长分化因子-15可有效对急性胸痛患者进行早期危险

生长分化因子-15（GDF-15）系机体应激反应产物之一，并可作为判别非ST段抬高型急性冠脉综合征患者继后复发再梗死和死亡风险增加的生物指标之一。然而迄今关于对急性胸痛患者进行有效早期危险分层的相关指标既少又欠可靠。现就GDF-15在对非选择性急性胸痛患者进行早期危险分层中的有效性和可靠性进行评估。     

护理团队在“胸痛中心”建设中的作用

正胸痛是急诊患者常见症状之一,占急诊就诊人数的5%~30%[1]。以胸痛为表现的急危重症如急性冠脉综合征、主动脉夹层、急性肺栓塞、张力性气胸等均具有诊断困难、救治时间窗短的特点,故对胸痛患者进行合理的危险分层,并给予正确的诊断和及时的治疗至关重要。为规范胸痛患者的诊治流程,改善患者预后,自2011年起,我国在全国范围内推广"胸痛中心"建设。"胸痛中心"是为以急性胸痛为主要临床表现的急危     

急性肺栓塞常用危险分层评估研究进展

急性肺栓塞（APE）发病率逐年上升,但缺乏临床特异性症状及体征。一旦确诊APE,对患者进行早期危险分层并采取对应的治疗措施,可显著改善患者临床预后。本文就目前常用的几种APE危险分层评估工具进行综述,为临床诊疗与后续研究提供一定理论依据和思路。     

超敏肌钙蛋白在急性冠状动脉综合征中的临床应用

急性心肌梗死的早期诊断和及时进行再灌注治疗为降低死亡率的关键,故对因急性胸痛就诊的患者进行快速、正确的评估以及危险分层尤为重要;而评估心肌坏死的特异性生化标记物为急性心肌梗死诊断、监测病程与评价预后的主要指标之一。近期发展的超敏肌钙蛋白(hsTn)的检测技术可更精确地测定肌钙蛋白(cTn)的浓度并可检测99%健康人群以上的异常值,其不仅可提高急性心肌梗死的诊断率,亦可进一步进行危险分层,可用于急性冠状动脉综合征患者的长期风险评估。     

高敏心肌肌钙蛋白在冠心病中的应用研究进展

高敏心肌肌钙蛋白检测因较高的敏感性及阴性预测值,显著提高急性冠状动脉综合征患者的诊断准确性并缩短诊断时间,目前被广泛应用于急性胸痛患者的早期诊断。在稳定性冠心病患者中,依据高敏心肌肌钙蛋白水平进行危险分层对患者预后有提示作用。近年来,诸多研究表明高敏心肌肌钙蛋白检测在急性冠状动脉综合征诊断及稳定性冠心病预后评价方面有重要价值,现对高敏心肌肌钙蛋白在冠心病中的应用研究进展进行综述。     

多排螺旋CT造影在急性胸痛诊断中的应用进展

急性胸痛是严重威胁人类生命的重大疾病,早期诊断对疾病的积极治疗及预后具有至关重要的作用。目前急性胸痛的早期诊断主要采用回顾性心电门控CT造影成像,本文就目前国内外影像学检查在急性胸痛诊断中的应用进展进行分析。     

胸痛三联征CT检查的护理措施与应用

正胸痛是常见的临床症状,根据其病因不同,大致可分为心脏缺血性胸痛(如急性冠脉综合征)和非心脏缺血性胸痛(如主动脉夹层动脉瘤、肺栓塞、气胸、胃食管疾病)。不同胸痛的性质及其危险程度、预后和转归截然不同,对于高危患者,救治的效果有明显的时间依赖性,早期诊断,早期对症治疗,才能最大程度地减少并发症,降低病死率。急性胸痛病因繁复,症状缺乏特异性,起病紧急,表现凶险,其中急性冠状动脉综合征,急性肺动脉栓塞和主动脉夹层动脉病是严重     

不同生物标志物在急性肺血栓栓塞症中的应用价值

急性肺血栓栓塞症是临床上的急危重症,其症状多为胸痛、呼吸困难、晕厥等,易与其他心血管急症相混淆,在急诊室如何快速诊断并评估患者危险分层以指导临床治疗尤为重要,而其中生物标志物的作用越来越受到重视。目前最常用的生物标志物有D-二聚体、脑钠肽、肌钙蛋白等。此外,近年研究发现脂肪酸结合蛋白、microRNA也有助于肺栓塞的危险分层和评估预后。一些炎症指标也有助于肺栓塞的预后评估。随着可用于监测的生物标志物的增加,如何合理选用生物标志物并正确分析其内涵尚缺乏系统性的认识。现主要对生物标志物在急性肺血栓栓塞症的诊断、危险分层、预后评估等方面的作用进行综述。     

hs-CRP、TPI联合HEART评分系统在急性心源性胸痛中的应用及对主要不良心血管事件的预测价值

目的探讨超敏-C反应蛋白(hs-CRP)、肌钙蛋白I(TPI)联合HEART评分系统在急性心源性胸痛中的应用及对主要不良心血管事件(MACE)的预测价值。方法选择194例急性胸痛患者依据胸痛病因分为急性心源性胸痛组(n=108)和急性非心源性胸痛组(n=86),比较各组hs-CRP、TPI联合HEART评分,并按照HEART评分对急性心源性胸痛患者进行危险度分层(分为高危组、中危组、低危组),记录随访3个月MACE发生情况。结果急性心源性胸痛组hs-CRP、TPI及HEART评分高于急性非心源性胸痛组(P0.05),急性心肌梗死患者的hs-CRP、TPI及HEART评分高于心绞痛患者(P0.05)。急性心源性胸痛高危组患者中hs-CRP、TPI及HEART评分高于中危组及低危组,中危组患者的hs-CRP、TPI及HEART评分高于低危组(P0.05)。急性心源性胸痛高危组MACE总发生率高于中危组,中危组MACE总发生率高于低危组(P0.05)。有MACE者的hs-CRP、TPI及HEART评分高于无MACE者(P0.05)。hs-CRP、TPI、HEART评分、hs-CRP+TPI+HEART评分对急性心源性胸痛MACE预测的ROC曲线下面积分别为0.626、0.764、0.709、0.866。结论 hs-CRP、TPI联合HEART评分系统有利于急性心源性胸痛的定性诊断和危险分层,且对患者短期内MACE的发生有较高的预测价值。     

非ST段抬高急性冠脉综合征的危险分层及治疗策略

非ST段抬高急性冠脉综合征患者发病率高、生存率低,合理的治疗策略选择非常重要,早期的危险分层则是治疗策略选择的关键环节。现对非ST段抬高急性冠脉综合征危险分层及预后评价的现状进行回顾,并就其治疗策略的选择做一综述。     

Markers and the initial triage and treatment of patients with chest pain

Emergency departments evaluate nearly 8 million patients with chest pain per year. Nearly 4 million of these individuals are admitted to inpatient units for further evaluation and treatment, but only 30% of these admitted patients ultimately have the diagnosis of acute coronary syndrome (ACS). Previously, the initial evaluation of patients with chest discomfort presenting to the emergency department (ED) involved the triad of history, physical, and ECG. Current evidence demonstrates that a fourth element, cardiac markers, serves as a valuable aid in not only determining initial diagnosis but also providing risk stratification and dictating initial patient treatment. Chest pain units (CPUs) using serial marker determinations have been successful in identifying patients with or at risk for adverse cardiac events in a timely and cost- efficient manner. New point-of-care-testing (POCT) of cardiac markers at the patient's bedside allows for even more timely determination. This article will review the use of cardiac markers in heterogeneous patients presenting to EDs with chest discomfort. We will focus on the use of markers in the risk stratification and initial treatment of the ED chest pain population and emphasize the role of CPUs and POCT.     

Coronary Computed Tomography Angiography in the Assessment of Acute Chest Pain in the Emergency Room

The coronary computed tomography angiography has recently emerged as an accurate diagnostic tool in the evaluation of coronary artery disease, providing diagnostic and prognostic data that correlate directly with the data provided by invasive coronary angiography. The association of recent technological developments has allowed improved temporal resolution and better spatial coverage of the cardiac volume with significant reduction in radiation dose, and with the crucial need for more effective protocols of risk stratification of patients with chest pain in the emergency room, recent evaluation of the computed tomography coronary angiography has been performed in the setting of acute chest pain, as about two thirds of invasive coronary angiographies show no significantly obstructive coronary artery disease. In daily practice, without the use of more efficient technologies, such as coronary angiography by computed tomography, safe and efficient stratification of patients with acute chest pain remains a challenge to the medical team in the emergency room.Recently, several studies, including three randomized trials, showed favorable results with the use of this technology in the emergency department for patients with low to intermediate likelihood of coronary artery disease. In this review, we show data resulting from coronary angiography by computed tomography in risk stratification of patients with chest pain in the emergency room, its diagnostic value, prognosis and cost-effectiveness and a critical analysis of recently published multicenter studies.     

Identifying patient risk: The basis for rational discharge planning after acute myocardial infarction

Variations in the management of patients with chest pain and acute myocardial infarction (MI) can significantly affect hospital length of stay and cost. Risk stratification of such patients, combined with data about effective therapies, provides the basis for developing rational guide-lines for patient care that can improve efficiency while maintaining quality of care. Such standardized management approaches are often referred to as pathways or CareMaps. To be most effective in guiding hospital course and early discharge planning, risk stratification strategies must be applied early in a patient's course with continuous updating. The process of identifying risk in a patient with acute chest pain occurs in two segments: assessing the risk of acute MI at presentation, and subsequently assessing the morbidity and mortality risk of patients diagnosed with acute MI. Identification of patient risk at presentation has been the subject of intense investigation. The history, physical exam, initial electrocardiogram, and cardiac enzymes are the mainstays of the process, but because of inherent weaknesses in this approach (>25% of acute MIs missed at the initial screening), several risk stratification models have been developed. To date these models have not been widely employed, however. Very sensitive early cardiac markers, such as troponin T, and the use of diagnostic echocardiography or cardiolite perfusion imaging during pain are also being investigated. Chest pain observation units are an alternate strategy and have obviated the need to admit many low- to moderate-risk chest pain patients. In these protocol-driven units, continuous physiologic monitoring and serial cardiac enzymes and electrocardiography over a 9–12 hour period refine the risk assessment. For the majority who rule out, the risk of subsequent MI or death is very low. Cost savings due to reduced length of stay and more efficient resource utilization are 63–76% compared with conventional ward or cardiac care unit management. For patients with acute MI, baseline characteristics, complications, and laboratory and diagnostic testing help define the risk of morbidity and mortality and guide management through the immediate post-MI phase and long term. Many models incorporating these features have been proposed for risk stratification after acute MI, and they have implications for both timing of discharge and necessary diagnostic testing. Savings by employing risk stratification to guide hospital course and discharge planning could be 30–44% in some patient groups. In conclusion, risk stratification models can facilitate early discharge planning, potentially reducing hospital stay, improving resource utilization, and reducing costs.     

Myocardial perfusion imaging in evaluation of undiagnosed acute chest pain

Abstract
Myocardial perfusion imaging is a relatively new technique in the emergency department management of acute chest pain. With improved sensitivity and specificity compared to traditional methods of risk stratification, an abnormal scan rapidly identifies individuals with acute perfusion abnormalities and allows the appropriate utilization of limited resources. Conversely, a normal scan allows prompt hospital discharge and is associated with excellent outcomes both in the short and medium terms. Acute chest pain myocardial perfusion imaging has been demonstrated to alter patient management and disposition and its routine use results in decreased costs in the intermediate risk population. (Intern Med J 2001; 31: 544–546)     

Risk scores for patients with chest pain: evaluation in the emergency department

Chest pain is a common reason for presentation to the emergency department (ED). Absolute criteria for Acute Coronary Syndrome without ST elevation (NSTE-ACS) are lacking. An acute coronary syndrome (ACS) needs to be distinguished from a variety of other cardiac and non-cardiac diseases that may cause chest pain.For patients with confirmed ACS, several scoring methods can be applied in order to distinguish patients in the coronary care unit who may benefit most from therapies. The PURSUIT, TIMI, GRACE and FRISC risk scores are well validated with this respect. However, none of these risk scores has been used in the identification of an ACS in the emergency setting. The vast majority of patients with chest pain due to causes other than ACS were not evaluated in these trials. An evidence-based systematic stratification and policy for these patients does not currently exist.The more recently developed HEART score is specifically designed to stratify all chest pain patients in the ED. The HEART score was validated in a retrospective multicenter study and proved to be a strong predictor of event free survival on one hand and potentially life threatening cardiac events on the other hand. The HEART score facilitates risk stratification of chest pain patients in the ED.     

Improved risk stratification in unstable angina: Identification of patients at low risk for in-hospital cardiac events by admission echocardiography

Current protocols for risk stratification of patients with acute chest pain syndromes rely on clinical parameters and are oriented toward identification of patients at high risk for adverse cardiac events; however, this paradigm for risk stratification does not adequately address the observation that adverse cardiac events are relatively uncommon in this population. In an era of cost containment, consideration also should be given to identification of patients at low risk for adverse cardiac events, who may be safely discharged without expensive inpatient hospitalization.     

Wall thickening assessment with tissue harmonic echocardiography results in improved risk stratification for patients with non-ST-segment elevation acute chest pain.

OBJECTIVES: To demonstrate whether the improved imaging quality gained by using tissue harmonic echocardiography in place of fundamental echocardiography results in the improved risk stratification of patients presenting with non-ST-elevation acute chest pain. METHODS AND RESULTS: Eighty patients with over 30 min of non-ST-elevation chest pain that had lasted less than 6 h were recruited. All patients underwent resting tissue harmonic and fundamental echocardiographic scans. Diagnosis for acute myocardial infarction was made on a 24 h creatine kinase-MB sample. Echocardiographic images were reported by two experienced blinded observers. Patients were followed up at least 4 months after admission. Endpoints included all-cause mortality, non-fatal myocardial infarction and revascularisation procedures. Tissue harmonic echocardiography allowed assessment of all myocardial segments in all patients compared to 43/78 patients ( p<0.001 ) with fundamental echocardiography. A wall thickening abnormality demonstrated on tissue harmonic echocardiography and not fundamental echocardiography was a significant predictor of index myocardial infarction on admission ( p<0.007 ) and for an adverse cardiac event during follow up ( p=0.002 ). CONCLUSIONS: Tissue harmonic echocardiography is superior to fundamental echocardiography for accurate assessment of systolic wall thickening and hence risk stratification for patients presenting with acute chest pain and non-diagnostic electrocardiogram changes.     

How to use ECG for decision support in the catheterization laboratory. Cases with inferior ST elevation myocardial infarction

Treatment of acute myocardial infarction has changed considerably during the last few years with the introduction of primary coronary angioplasty. In the acute phase risk stratification is largely based on simple clinical parameters, laboratory markers of myocardial injury and 12-lead electrocardiography. The electrocardiogram is of crucial importance especially during the first few hours after initiation of chest pain when important therapeutic decisions are made. Biochemical markers of myocardial injury are usually not elevated at that time point. Cases with inferior ST-elevation myocardial infarction from our hospital are presented to show how anatomical interpretation of ECG recorded during chest pain helps to risk stratify patients.     

Acute coronary syndromes: risk stratification and initial management

For patients who have acute coronary syndromes (ACS), risk stratification is key to initiating appropriate treatment. For ST-segment elevation MI, immediate reperfusion therapy is needed, and thus rapid identification of ST elevation on the ECG is critical. Then, having a standardized protocol for rapid treatment- with either primary percutaneous coronary intervention or thrombolysis - is critical. For unstable angina/non-ST elevation ACS, after first identifying the patients who have a higher likelihood of actually having an ACS (as opposed to noncardiac chest pain) stratification to high versus lower risk is needed to choose appropriate therapies. Thus, it is important for risk stratification to be a central part of all management of patients who have ACS.     

Design of the Rule Out Myocardial Ischemia/Infarction Using Computer Assisted Tomography: a multicenter randomized comparative effectiveness trial of cardiac computed tomography versus alternative triage strategies in patients with acute chest pain in the emergency department

Although early cardiac computed tomographic angiography (CCTA) might improve the management of emergency department (ED) patients with acute chest pain, it could also result in increased testing, costs, and radiation exposure. ROMICAT II was a randomized comparative effectiveness trial enrolling patients 40 to 74 years old without known coronary artery disease who presented to the ED with chest pain but without ischemic electrocardiographic (ECG) changes or elevated initial troponin and who required further risk stratification. Overall, 1000 patients at 9 sites within the United States were randomized to either CCTA as the first diagnostic test following serial biomarkers or to standard of care, which included no testing or functional testing such as exercise ECG, stress radionuclide imaging, or stress echocardiography. Test results were provided to ED physicians, yet patient management was not driven by a study protocol in either arm. Data were collected on diagnostic testing, cardiac events, and cost of medical care for the index hospitalization and during the following 28 days. The primary end point was length of hospital stay. Secondary end points were cumulative radiation exposure, resource utilization, and costs of competing strategies. Tertiary end points were institutional, physician, and patient characteristics associated with primary and secondary outcomes. Rate of missed acute coronary syndrome within 28 days was the safety end point. The ROMICAT II will provide rigorous data on whether CCTA is more efficient than standard of care in the management of patients with acute chest pain at intermediate risk for acute coronary syndrome.