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Estratificación del riesgo de pacientes con dolor torácico sin elevación del segmento ST en la puerta de urgencias

2003; Elsevier BV; Volume: 56; Issue: 10 Linguagem: Inglês

10.1157/13052383

1579-2242

Juan Sanchís, Vicent Bodí, Ángel Llácer, Lorenzo Fácila, Mauricio Pellicer, Vicente Bertoméu, Julio Núñez, Vicent Ruiz, Francisco J. Chorro,

Cardiac Structural Anomalies and Repair

Investigar en la puerta de urgencias los factores pronosticos de pacientes que acuden por dolor toracico sin elevacion del segmento ST. Se evaluo a 743 pacientes consecutivos mediante la historia clinica, el electrocardiograma, la determinacion de troponina I y la ergometria precoz (< 24 h) en el subgrupo de bajo riesgo (n = 203). Todos los pacientes fueron seguidos durante 3 meses, y se recogieron los eventos mayores (infarto agudo de miocardio o muerte). En 71 pacientes (9,6%) ocurrieron eventos mayores. En el analisis multivariable (estadistico C = 0,79; IC del 95%, 0,73-0,84; p = 0,0001) se identificaron los siguientes predictores: edad ≥ 72 anos (OR = 1,7; IC del 95%, 1,0-2,9; p = 0,05), diabetes insulinodependiente (OR = 2,9; IC del 95%, 1,5-5,4; p = 0,001), cardiopatia isquemica previa (OR = 1,9; IC del 95%, 1,1-3,2; p = 0,02), descenso del segmento ST (OR = 2,1; IC del 95%,1,2-3,8; p = 0,01) y elevacion de la troponina I (OR = 2,9; IC del 95%, 1,5-5,3; p = 0,001). Se creo una puntuacion de riesgo basada en las OR de estos 5 predictores que permitio la estratificacion de la poblacion por cuartiles de esta puntuacion: 0-2 puntos, 1,6% eventos; 3-4 puntos, 8,1% eventos; 5-7 puntos, 11,9% eventos; ≥ 8 puntos, 26,2% eventos; p = 0,0001. Ningun paciente con ergometria precoz negativa presento eventos. En los pacientes con dolor toracico, el conjunto de los datos clinicos, electrocardiograficos y bioquimicos disponibles en la puerta de urgencias permite establecer una rapida estratificacion pronostica. La ergometria precoz es util para la estratificacion final en los pacientes de bajo riesgo. To investigate the prognostic factors in patients who come to the emergency room with chest pain but without ST segment elevation. 743 consecutive patients were evaluated by recording clinical history, electrocardiogram and troponin I determination, and early (< 24 h) exercise testing was done for the low-risk subgroup of patients (n = 203). All patients were followed during 3 months for major events (acute myocardial infarction or death). Major events occurred in 71 patients (9.6%). Multivariate analysis (C stadistic = 0.79; 95% CI 0.73-0.84; p = 0.0001) identified the following predictors: age ≥ 72 years (OR = 1.7; 95% CI, 1.0-2.9; p = 0.05), insulindependent diabetes mellitus (OR = 2.9; 95% CI, 1.5-5.4; p = 0.001), previous ischemic heart disease (OR = 1.9; 95% CI, 1.1-3.2; p = 0.02), ST depression (OR = 2.1; 95% CI, 1.2-3.8; p = 0.01) and troponin I elevation (OR = 2.9; 95% CI, 1.5-5.3; p = 0.001). These five predictors were used to construct a risk score based on their odds ratios, which allowed event rate stratification by quartiles of the score: 0-2 points (1.6% events), 3-4 points (8.1% events), 5-7 points (11.9% events) and ≥ 8 points (26.2% events); p = 0.0001. No patient with negative findings in the early exercise testing had major events. In patients with chest pain, the combination of clinical, electrocardiographic and biochemical data available on admission to the emergency service allows rapid prognostic stratification. Early exercise testing is advisable for the final stratification of low risk patients.