Czy 2 godziny wystarczą by wykluczyć NST-OZW ? Nowozelandczycy udowadniają, że tak.

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Pacjenci z bólem w klatce piersiowej stanowią liczną grupę wśród wszystkich chorych zgłaszających się do SOR-ów i Izb Przyjęć. Wyłączając nieliczne sytuacje, w których przyczyna bólu jest oczywista (np.: widoczny uraz), w różnicowaniu zawsze należy wziąć pod uwagę ostry zespół  wieńcowy (OZW). Standardowa ścieżka postępowania, mająca na celu wykluczenie sercowego pochodzenie zgłaszanych dolegliwości, obejmuje EKG oraz pomiar aktywności troponin przy przyjęciu oraz po kolejnych 6 godzinach. Doliczając czas oczekiwania na wyniki tych badań, pobyt chorego w szpitalu sięga nierzadko 8 h. Jest to nie tylko uciążliwe dla samego pacjenta, ale także obciążające dla organizacji pracy SOR-u, który dysponuje przecież ograniczoną ilością łóżek dla chorych wymagających obserwacji przed ewentualnym przyjęciem do szpitala. W tej sytuacji samo nasuwa się pytanie, czy nie istnieje szybszy, ale zarazem bezpieczny dla chorych, schemat diagnostyczny pozwalający wykluczyć lub potwierdzić OZW.

W opublikowanym niedawno w piśmie JAMA artykule[1] możemy przeczytać o próbie oceny schematu postępowania diagnostycznego, który pozwoliłby w istotny sposób skrócić średni czas diagnostyki pacjentów  z bólem w klatce piersiowej. Naukowcy z Nowej Zelandii zaproponowali by u osób biorących udział w badaniu prawdopodobieństwo ostrego zespołu wieńcowego ewaluować przy użyciu znanego z obserwacyjnego badania ASPECT[2] protokołu ADP (dwa zapisy EKG oraz dwa pomiary aktywności tropniny I w odstępie 2 h oraz ocena ryzyka OZW za pomocą zmodyfikowanej skali TIMI). Grupę kontrolną mieli stanowić chorzy, u których stosowano standardowy protokół diagnostyczny obejmujący EKG oraz ocenę aktywności troponiny I w odstępie 6-12h. Udział w badaniu proponowano wszystkim dorosłym, w pełni świadomym pacjentom, którzy między październikiem 2010, a lipcem 2012 trafili do miejscowego oddziału ratunkowego z podejrzeniem OZW bez uniesienia odcinka ST. Łącznie stosowaną zgodę wyraziły 542 osoby, spośród których 270 trafiło do grupy badanej. Jako punkt końcowy przyjęto zakończenie procedury diagnostycznej oraz opuszczenie przez chorego szpitala w 6 godzin od przyjęcia, przy jednoczesnym zachowaniu wymogów bezpieczeństwa – 30-dniowy okres obserwacji wolny od poważnych zdarzeń sercowo-naczyniowych (zgon, zatrzymanie krążenia, zawał, pilna angioplastyka, zaburzenia rytmu i przewodzenia wymagające interwencji). Opisywany punkt końcowy udało się osiągnąć w przypadku 52 spośród 270 osób (19,3%) w grupie badanej oraz u 30 na 270 pacjentów (11%) w grupie kontrolnej. Jednocześnie nie obserwowano między grupami istotnej statystycznie różnicy pod względem częstości występowania wymienionych wyżej zdarzeń sercowo-naczyniowych. Tylko jeden pacjent należący do grupy badanej doświadczył takiego zdarzenia w ciągu 30-dniowego okresu obserwacji po wypisie ( był to efekt błędu diagnostycznego, niezależnego od przyjętego schematu postępowania). W grupie kontrolnej takich przypadków nie odnotowano wcale.

Podsumowując można stwierdzić, że w badanej grupie chorych schemat ADP testowany przez badaczy spełnił swoje zadanie, dając możliwość szybszego i co najważniejsze trafnego typowania chorych niskiego ryzyka. Jego użycie w praktyce poprawiło komfort chorych, oszczędzając im nadmiernie długiego pobytu w oddziale ratunkowym, a jego wdrożenie nie wiązało się z koniecznością poświęcenia dodatkowych środków finansowych.

1. Than M et al., A 2-hour diagnostic protocol for possible cardiac chest pain in the emergency department: a randomized clinical trial. JAMA Intern Med. 1 Jan 2014; 174(1):51-8

2. Than M et al., A 2-h diagnostic protocol to assess patients with chest pain symptoms I the Asia-Pacific region (ASPECT): a prospective observational validation study. Lancet.  26 Mar 2011; 26;377(9771):1077-84


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