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首页> 外文期刊>The Internet Journal of Emergency and Intensive Care Medicine >A Novel Noninvasive Myocardial Performance Index For Ruling Out Acute Coronary Syndrome In The Emergency Department
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A Novel Noninvasive Myocardial Performance Index For Ruling Out Acute Coronary Syndrome In The Emergency Department

机译：排除急诊科急性冠脉综合征的新型无创心肌性能指标

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Definitive diagnosis in patients presenting to the emergency department (ED) with chest pain is difficult due to limitations of the electrocardiogram (ECG) as the primary assessment tool. Most patients presenting with chest discomfort have a nonischemic ECG and biomarkers of myocardial necrosis within normal limits. Because of the limitation of initial risk stratification tools, many patients who do not actually have acute coronary syndrome (ACS) are admitted to hospital. The current study describes a new, noninvasive apparatus that quantifies central aortic pressure changes (dP/dtejc), an established indicator of myocardial contractility. We hypothesize that a higher dP/dtejc occurs in non ischemic chest pain than during ischemic chest pain. This appears to be a result of reduced myocardial contractility during ischemia, whereas chest pain of non cardiac origin increases dP/dtejc by the stress of the pain itself. The study follows 102 patients presenting at the ED with acute chest pain. In 55 patients, the device indicated chest pain to be of non cardiac origin (dP/dtejc index above threshold value of ≥150). Of these 55, negative ECG and myocardial enzyme dynamics ruled out coronary origin during the first twenty-four hours after admission (sensitivity 93%, negative predictive value 98% specificity 61%, positive predictive value 28%, accuracy 66%). Initial findings indicate that adding noninvasive dP/dtejc measurements to the classical triage of chest pain in the ED could help prevent unnecessary hospitalization in a substantial number of patients with low probability for ACS. Introduction Patients with chest pain account for more than 6 million ED visits per year in the United States alone (1). For these patients, the ECG remains the most important initial risk assessment tool. Myocardial ischemia or infarction is highly likely in patients with significant ST segment changes on the ECG or elevation in myocardial markers of necrosis. Identification of high-risk patients is more difficult in those with non ischemic ECG and negative markers on presentation. Because initial evaluation often does not yield a definitive diagnosis, one important aspect of the ED evaluation of the patient with chest pain is risk stratification. Low-risk patients account for nearly 2/3 of those presenting to the ED with chest pain, representing as many as 4 million patients per year in the United States (2).One of the most sensitive indices of contractility is the rate of increase of intraventricular pressure during isovolumetric contraction, (left ventricular dP/dt and arterial dP/dt). Dp/dt (dP/dt ejc ) represents the rate of change of pressure during ejection (3,4,5,6). It has been shown that cardiac contractility and dP/dt decreases during acute myocardial ischemia (3, 5). We theorized that a higher value of dP/dt would be found for non ischemic chest pain than during ischemic chest pain because ischemia reduces myocardial contractility, whereas chest pain of non cardiac origin increases dP/dt by the stress of the pain itself. The current study describes a new, noninvasive device that measures central aortic pressure changes (dP/dt ejc ), a parameter that could be added to the diagnostic triage of ischemia in the ED, thus decreasing the number of unnecessary admissions. Methods Patient Population & Setting:The study group consisted of 74 men and 28 women admitted to the ED for chest pain. Mean age was 67 (range 19-95). Patients were included if they were aged over 18, chest pain had lasted less than 12 hours, there was no history of trauma and no other medical causes of chest pain had been diagnosed. Patients with arrhythmia were excluded. The study complies with the Declaration of Helsinki. The locally appointed ethics committee approved the research protocol and informed consent was obtained from all of the patients.The following indicators were considered for detecting myocardial necrosis: Maximal concentration of Troponin I exeeding the decis
机译：由于作为主要评估工具的心电图（ECG）的局限性，很难就诊到急诊科（ED）并伴有胸痛的患者。大多数表现出胸部不适的患者在正常范围内均具有非缺血性ECG和心肌坏死的生物标志物。由于初始风险分层工具的局限性，许多实际上没有急性冠脉综合征（ACS）的患者被送入医院。当前的研究描述了一种新的，无创的设备，该设备可量化中心主动脉压力变化（dP / dtejc），这是心肌收缩力的既定指标。我们假设非缺血性胸痛的发生率高于缺血性胸痛的发生率。这似乎是缺血期间心肌收缩力降低的结果，而非心脏起源的胸痛因疼痛本身的压力而增加dP / dtejc。这项研究追踪了102名急诊急症患者。在55位患者中，该设备显示胸痛是非心脏起源的（dP / dtejc指数高于阈值≥150）。在这55例患者中，ECG和心肌酶动力学阴性排除了入院后24小时内的冠状动脉起源（敏感性93％，阴性预测值98％特异性61％，阳性预测值28％，准确度66％）。初步发现表明，将无创dP / dtejc测量值添加到ED中经典的胸痛分流方法中，可以帮助预防大量ACS可能性较低的患者不必要的住院治疗。简介仅在美国，每年就有超过600万例急诊就诊为胸痛患者（1）。对于这些患者，心电图仍然是最重要的初始风险评估工具。心电图上ST段明显改变或坏死的心肌标志物升高的患者极有可能发生心肌缺血或梗塞。对于非缺血性ECG且呈示标记为阴性的患者，识别高危患者更为困难。由于最初的评估通常无法做出明确的诊断，因此对胸痛患者进行ED评估的一个重要方面是风险分层。低风险患者占急诊科胸痛患者的近2/3，在美国每年代表多达400万患者（2）。收缩率最敏感的指标之一是增加率等容收缩过程中心室内压的变化（左心室dP / dt和动脉dP / dt）。 Dp / dt（dP / dt ejc）表示喷射过程中压力的变化率（3,4,5,6）。研究表明，急性心肌缺血期间心脏收缩力和dP / dt降低（3，5）。我们的理论认为，与缺血性胸痛相比，非缺血性胸痛的dP / dt值更高，因为缺血会降低心肌的收缩力，而非心脏性胸痛会因疼痛本身的压力而增加dP / dt。当前的研究描述了一种新的非侵入性设备，该设备可以测量主动脉中央压力变化（dP / dt ejc），该参数可以添加到ED缺血性诊断分类中，从而减少不必要的入院次数。方法患者人群和环境：研究组由74名男性和28名女性因胸痛入院。平均年龄为67岁（范围为19-95）。如果患者年龄超过18岁，胸痛持续时间少于12小时，没有创伤史，也没有诊断出其他医学原因引起的胸痛，则包括在内。心律失常患者被排除在外。该研究符合赫尔辛基宣言。当地任命的伦理委员会批准了研究方案并从所有患者中获得了知情同意。考虑使用以下指标来检测心肌坏死：肌钙蛋白I的最高浓度已超出诊断标准。

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