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

基本信息

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
项目类别：
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

项目摘要

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.

项目概要该提案的最终目标是改善急诊科 (ED) 评估后的结果疑似急性冠状动脉综合征（ACS）。 ACS 包括急性心肌梗塞 (AMI) 和不稳定心肌梗塞心绞痛，是全世界死亡和发病的主要原因。疑似 ACS 是第二常见的是美国急诊科就诊的常见原因，每年就诊次数超过 700 万次。少数（13%）的 ED 胸痛就诊与 ACS 相关，由于临床和医学法律风险较高，诊断具有挑战性。为了尽量减少漏诊 ACS，美国心脏协会建议进行非侵入性心脏测试（例如压力测试）心电图 [ECG]、负荷超声心动图 [echo]、负荷心肌灌注 [MP] 或冠状动脉在系列生物标志物排除 AMI 后 72 小时内进行计算机断层扫描血管造影 [CCTA]）。此外，疑似 ACS 的患者经常被送入住院病床或观察室以进行观察。促进早期无创检测并降低缺血性心脏危险并发症的风险疾病。对疑似 ACS 的评估是美国短期住院（<48 小时）住院和观察的首要原因住院费用，每年造成 3-100 亿美元的医院费用。然而，没有证据表明早期无创检测或基于医院的评估有好处患者。目前早期非侵入性检查的使用增加了侵入性冠状动脉造影和血运重建不会降低 AMI 风险。低风险患者住院的潜在好处似乎处于边缘状态（入院期间心脏事件发生率<0.2%）。非侵入性的比率差异很大检测（前四分位医院和后四分位医院之间的 6 倍差异）和住院治疗（前四分位医院之间的 7 倍差异）和垫底四分位医院）对于疑似 ACS 的治疗表明最佳方法普遍存在不确定性。利用综合卫生系统内约 170,000 名患者的前瞻性观察数据，我们将评估五项早期诊断（负荷心电图、负荷超声、负荷 MP、CCTA 或 NO 无创测试）以及三种处置（住院、观察、出院）策略：目标 1. 比较疑似 ACS 早期诊断测试策略的 30 天结果目标 2. 比较疑似 ACS 处置策略的 30 天结果目标 3. 评估预测试风险是否影响早期诊断和早期诊断的相对有效性疑似 ACS 的处置策略目标 4. 比较疑似 ACS 的早期诊断和处置策略的成本效益这些目标解决了对疑似 ACS 进行任何评估的基本问题： 1. 如果需要的话，需要进行什么测试？ 2. 入学有好处吗？ 3. 患者预检风险如何调整管理？目标 4 将告知政策制造商和付款人了解不同策略的比较价值。