Safety of Using Risk Stratification Along With High-Sensitivity Cardiac Troponin in the Emergency Department: A Secondary Analysis.

Whether gains are similar in low- and intermediate-risk patients and those discharged were correctly identified as being at lower risk of future cardiovascular events is uncertain.

在低风险和中等风险患者中，以及那些被正确识别为未来心血管事件风险较低的出院患者中，是否能获得相同的收益尚不明确。

This study sought to evaluate the effectiveness and safety of risk stratification with high-sensitivity cardiac troponin in patients with suspected acute coronary syndrome stratified as low and intermediate risk.

本研究旨在评估在疑似急性冠状动脉综合征患者中，使用高敏心肌肌钙蛋白进行低危和中危风险分层的有效性和安全性。

Methods

In this secondary analysis of a stepped-wedge cluster-randomized controlled trial, we evaluated the effectiveness and safety of risk stratification with high-sensitivity cardiac troponin in 31,492 consecutive patients who presented with suspected acute coronary syndrome and identified as low (<5 ng/L) or intermediate (5 ng/L to 99th percentile) risk at presentation.

在这项阶梯楔形群随机对照试验的次要分析中，我们评估了在31,492名连续出现疑似急性冠状动脉综合征且入院时被识别为低危（<5 ng/L）或中危（5 ng/L至99百分位数）风险的患者中，使用高敏心肌肌钙蛋白进行风险分层的有效性和安全性。

The primary effectiveness outcome was length of hospital stay.

主要有效性结果是住院时长。

The primary safety outcome was subsequent myocardial infarction or cardiac death at 1 year.

主要安全性结果是1年内发生的心肌梗死或心脏死亡。

Results

Of 31,492 patients (59 ± 17 years, 45% women), 17,299 (54.9%) and 14,193 (45.1%) were low and intermediate risk, respectively.

在31,492名患者中（平均年龄59±17岁，女性占45%），17,299名（54.9%）为低风险患者，14,193名（45.1%）为中等风险患者。

Following implementation, length of stay was reduced in low-risk (6.9 ± 3.2 vs 4.7 ± 2.8 hours: difference 2.2; 95% CI: 0.7-3.7 hours) and intermediate-risk (15.8 ± 4.7 vs 11.0 ± 4.9 hours: difference 4.8; 95% CI: 3.8-5.8 hours) patients (P < 0.001 for both).

实施后，低风险患者住院时间减少（6.9±3.2小时对比4.7±2.8小时：差异2.2小时；95%置信区间：0.7-3.7小时），中等风险患者住院时间也减少（15.8±4.7小时对比11.0±4.9小时：差异4.8小时；95%置信区间：3.8-5.8小时）（两者P值均<0.001）。

Discharge from the emergency department increased in low-risk (62% [4,962 of 7,941] vs 83% [7,747 of 9,358]; adjusted OR: 3.31; 95% CI: 3.06-3.57) and intermediate-risk (36% [2,445 of 6,759] vs 55% [4,095 of 7,434]; adjusted OR: 2.06; 95% CI: 1.92-2.21) patients.

急诊科出院率在低风险患者中增加（62% [4,962/7,941] 对比 83% [7,747/9,358]；调整后比值比：3.31；95% 置信区间：3.06-3.57），在中等风险患者中也有所增加（36% [2,445/6,759] 对比 55% [4,095/7,434]；调整后比值比：2.06；95% 置信区间：1.92-2.21）。

Following implementation, patients discharged were at lower risk of myocardial infarction or cardiac death at 1 year (1.5% [112 of 7,407] vs 1.0% [124 of 11,842]; adjusted HR [aHR]: 0.65; 95% CI: 0.50-0.86), whether stratified as low (0.6% vs 0.3%; aHR: 0.46; 95% CI: 0.26-0.83) or intermediate (3.4% vs 2.4%; aHR: 0.74; 95% CI: 0.55-0.99) risk at presentation.

实施后，患者在1年内发生心肌梗死或心脏死亡的风险降低（1.5% [112/7,407] 对比 1.0% [124/11,842]；调整后风险比[aHR]：0.65；95% 置信区间：0.50-0.86），无论是作为低风险（0.6% 对比 0.3%；aHR：0.46；95% 置信区间：0.26-0.83）还是中等风险（3.4% 对比 2.4%；aHR：0.74；95% 置信区间：0.55-0.99）患者出院。

Conclusions

Risk stratification with high-sensitivity cardiac troponin reduced length of stay and increased discharge from the emergency department in both low- and intermediate-risk patients with suspected acute coronary syndrome.

通过高敏心肌肌钙蛋白进行风险分层，降低了低风险和中等风险疑似急性冠状动脉综合征患者的住院时间，并提高了从急诊科出院的比例。

Patients discharged from the emergency department were at lower risk of subsequent myocardial infarction or cardiac death at 1 year.

从急诊科出院的患者在1年内发生心肌梗死或心脏死亡的风险较低。

(High-Sensitivity Cardiac Troponin on Presentation to Rule Out Myocardial Infarction [HiSTORIC]; NCT03005158).

(入院时高敏心肌肌钙蛋白排除心肌梗死研究[HiSTORIC]; NCT03005158).