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

• 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
• 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

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.

项目摘要 该提案的最终目标是在急诊科（ED）评估后改善结果 怀疑的急性冠状动脉综合征（ACS）。 ACS包括急性心肌梗塞（AMI）和不稳定 心绞痛，是全球死亡率和发病率的主要原因。怀疑的ACS是第二个 美国ED访问和账户的经常原因超过700万。 ED的少数（13％） 胸痛访问与AC有关，并且诊断具有较高的临床和法律风险，具有挑战性。 为了最大程度地减少ACS，美国心脏协会提出了非侵入性心脏测试（例如，压力 心电图[ECG]，应力超声心动图[Echo]，应力心肌灌注[MP]或冠状动脉 在连续生物标志物排除AMI之后，计算机断层扫描血管造影[CCTA]）在72小时内。 此外，怀疑ACS的患者通常被接纳为住院床或观察单位 促进早期非侵入性测试并减轻缺血性心脏并发症的风险 疾病。评估可疑的AC是美国短期（<48小时）住院和观察的主要原因 入院，每年的医院费用为3-100亿美元。 但是，没有证据表明早期非侵入性测试或基于医院的评估福利 患者。当前使用早期非侵入性测试增加了侵入性冠状动脉造影术和 血运重建而不会降低AMI风险。低风险患者入院的潜在益处 似乎是边际（入院期间<0.2％心脏事件率）。非侵入性的发生率很大 测试（顶部和底部四分位数医院之间的6倍差异）和住院（TOP之间的7倍差异 可疑AC的底部四分位数医院）提出了有关最佳方法的普遍不确定性。 使用综合卫生系统中约有170,000名患者遇到的前瞻性观察数据，我们 将评估五个早期诊断（压力ECG，压力回声，压力MP，CCTA或无侵入性测试）和 三种处置（住院，观察，出院）策略： 目标1。比较可疑ACS的早期诊断测试策略的30天结果 目标2。比较可疑ACS的处置策略的30天结果 目标3。评估测试前风险是否影响早期诊断的比较效率 可疑ACS的处置策略 目标4。比较可疑ACS的早期诊断和处置策略的成本效益 目的解决了对可疑AC的任何评估基础的问题：1。需要什么测试？ 2。入院有益吗？ 3。患者预测试风险如何改变管理？ AIM 4将为政策提供信息 制造商和付款人关于不同策略的比较价值。