Abstract 226: The Appropriate Use Of Stress Tests In Low Pretest Probability Of CAD

Abstract

Chest pain is the second most common complaint seen in ED and remains a leading diagnostic challenge. Multiple assessment tools are validated to predict the probability of coronary obstruction causing chest pain for appropriate diagnostic care. Although clear guidelines are available for intermediate and high-risk individuals, analysis by AHA for low-risk patients and the indication for cardiac imaging is ongoing. An observational retrospective analysis was performed of patients above 18 years admitted for ACS rule out chest pain from January 2019 to 2020 at Upstate University Hospital. Electronic records were reviewed for patient demographics, pre-test probability of CAD based on Diamond and Forrester (DF) model, troponins, ECG, stress test modality, if cardiac catheterization was required and 30-day readmission rate for MI. Exclusion criteria ensured using only low-risk patients, with heart scores of 1 or 2 depending on age. The study selected 173 patients, 107 (61.8%) females and 66 (38.1%) males. Stress tests were performed on 22 (20.6%) female patients and 14 (21.2%) male patients. No stress test yielded abnormal results or required cardiac catheterization. None had 30-day readmission for MI. The most common stress test modality was exercise ECHO (50%). All patients had a low pretest probability (<10%) but 21% underwent inappropriate stress testing, without a change in outcomes. The 2021 AHA guidelines for chest pain support no additional cardiac testing in the low-risk population within 30 days of presentation to ED. Prior to this update, guidelines broadly recommended stress testing for this cohort. Our study supplements new guidelines and is a quality metric evaluation. As guidelines are readily investigated and updated by field experts, evaluating their clinical use by referring providers is imperative. Our study highlights the challenges to diagnose CAD and the overestimation by current and unrevised DF and HEART scores. The overestimation coupled with financial reimbursement policies allow for unnecessary testing. Guidelines have outlined when not to order cardiac imaging, and future directives need to focus on comparing risk models to define probability of CAD, with the shift of demographics to older, female and with noncardiac symptoms.