κε Κουναλάκη,
περιγράφετε ακριβώς και δικές μου σκέψεις. Πως σε έναν ασθενή με υποψία (και τι είναι η υποψία, εννοώ πως ορίζεται?) οξέος στεφανιαίου συνδρόμου προχωράς σε παραπομπή διερεύνηση, κλπ? Και ειδικά χωρίς να έχεις εργαστηριακή κάλυψη.
Νομίζω δεν υπάρχει απάντηση, τουλάχιστον εγώ δεν έχω. Αλλά πιστεύω, ότι γνωρίζοντας κάποια δεδομένα αποφεύγουμε λάθη.
Αξίζει να δείτε το παρακάτω κείμενο. Είναι του A. Mattu καθηγητή Emergency Medicine στο Maryland. Περιγράφει ακριβώς αυτό το πρόβλημα και προτείνει λύσεις. Βέβαια, αυτά ισχύουν για εκεί. Απλά αξίζει να έχουμε γνώση πως αντιμετωπίζουν τέτοια ερωτήματα εκεί. Το κείμενο το έχω αλιεύσει από το medscape.
The question of whether patients with chest pain can be discharged from the emergency department (ED) for outpatient stress testing is a difficult one, and was rarely asked until just a few years ago. Until recently, it had been common practice to stratify patients with chest pain into 3 major groups: (1) definitely acute coronary syndrome (ACS), (2) possible ACS, and (3) unlikely ACS. Patients in group 1 would be admitted for treatment, such as aspirin, heparin, and reperfusion therapy. Patients in group 2 would be admitted for a workup for ACS, beginning with serial electrocardiography (ECG) monitoring and cardiac biomarker testing. If results of these tests were negative, the workup typically continued with stress testing. If findings on any of this workup testing turned out to be positive for ACS, the patient was moved into group 1 and treated accordingly. Patients in group 3 were discharged without any further plans for ACS workup.
Because of hospital administrative issues, such as overcrowding, limited inpatient resources, rising costs, and encouragement from managed care companies for lower-cost outpatient workups, patients in group 2 are being further divided by inpatient physicians into 3 more subgroups: groups 2a, 2b, and 2c. Group 2a would follow the original plan of serial ECG, biomarker measurements, and stress testing. Group 2b, however, is judged to be of lower risk for early adverse outcomes and as such is suitable for outpatient stress testing, usually within a few days. The decision on whether to move patients to group 2a vs group 2b is based primarily on physician judgment, not on any clinically relevant studies. Group 2c consists of patients that the inpatient physicians evaluate and consider appropriate to move into group 3, despite the original concerns of the emergency physicians. Once again, this is a judgment decision, not necessarily based on any good evidence.
As ED overcrowding has become a greater issue in our practice, more emergency and in-patient physicians have wondered why the ED doesn't distinguish between group 2a vs group 2b and therefore decide to discharge patients directly for an outpatient stress test. The recent publication of the American College of Cardiology/American Heart Association 2007 revised guidelines for the management of patients with non-ST-segment elevation ACS[1] has also brought this question to the forefront of chest pain evaluation. The new guidelines state that if patients have normal serial cardiac biomarker levels and ECG, they should undergo a stress test to provoke ischemia (this stress test can be done in the ED, in a chest pain unit, or in the hospital); however, if the patient is further risk-stratified to low risk, outpatient stress testing within 72 hours is reasonable. This discharge to outpatient testing can certainly be done from the ED after an expedited rule-out protocol consisting of serial biomarker measurement and ECG. The major problem, however, is that the guidelines don't clarify what is required to further risk-stratify a patient to low-risk status; after all, it's not just a matter of ruling out myocardial infarction.
What else is required to declare that a patient is low (enough) risk for outpatient testing? To date, I'm not aware of any literature or scoring systems that have specifically clarified which patients can be discharged for outpatient testing (group 2b). Even the popular TIMI (Thrombolysis In Myocardial Infarction) and GRACE (Global Registry of Acute Coronary Events) risk scores are intended to be used only for group 1 patients; they were never intended to be used for group 2 patients. Medicolegal concerns in the United States also play a large role in this decision. Emergency physicians share the concern that if a patient who has an adverse outcome before the 72-hour follow-up is discharged, the ED will be challenged to defend the decision to discharge the patient. With the benefit of hindsight, any "expert" could review a case and question the decision to risk-stratify a patient into group 2b, finding reasons why the patient should have been in group 2a instead. Although the inpatient physicians may lament the fact that they are more willing to make this decision, they are also held to a different standard of care than are emergency physicians, and so their practice patterns should not dictate emergency department care.
So what's the answer? Are there any patients that can be safely discharged from the ED for outpatient stress testing? Despite my comments above, I believe that there are some patients that can be discharged. Those patients should have negative results on serial biomarker testing and ECG (not just 1 set) and should have confirmed follow-up within 72 hours for stress testing to meet the guidelines. The discharging emergency physician should document every possible negative finding in the review of systems, and ideally the patient should have a normal ECG result. Any other recommendations I'd make are just my opinion, but the main point is that the chart should truly "read" like a low-risk patient, with no red flags such as diaphoresis or radiating pain, no pain at rest, and normal vital signs. In addition, there should be a documented discussion of the risk for ACS and the importance of adherence with follow-up. Finally, to comply with the guidelines, patients should be given "appropriate precautionary pharmacotherapy (eg, aspirin, sublingual nitroglycerin, or beta-blockers) while awaiting results of the stress test."[1]
Physicians should remember that standard of care is not determined by being right 100% of the time, but rather by providing care that would be considered "reasonable." The problem is that "reasonable" is very subjective, and until we as a society can agree on what is "reasonable," we'll continue to debate this question and similar ones for many years.
1. Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction: executive summary. Circulation. 2007;116:803-877.
Θέμα: Πόσο ηπαρίνη χορηγείτε σε οξύ στεφανιαίο σύνδρομο? (Αναγνώστηκε 6793 φορές)
23 Ιανουαρίου 2018, 11:09:34