Cardiac catheterization reduces resource utilization in patients with chronic chest pain

Abstract

The evaluation of patients with recurrent chest pain accounts for a significant proportion of the $274 billion annual cost of cardiovascular services in the United States. Our investigation examines the impact of coronary angiography on subsequent use of medical resources for evaluation of chest pain symptoms. The study seeks to determine whether a finding of noncritical coronary artery disease on cardiac catheterization leads to a reduced use of resources for subsequent evaluation and treatment of chest pain syndromes. Our study included 22 consecutive patients who had sought evaluation for chest pain symptoms, and who had persistence of symptoms after functional testing. Cardiac catheterization demonstrated angiographically mild coronary artery disease (stenosis less than 50%) in these patients. The patient cohort accounted for 22 emergency room evaluations and 41 ambulatory clinic evaluations in the 2.5 years before cardiac catheterization. In the 2.5-year period after catheterization, these patients had only 3 emergency room visits and 1 ambulatory clinic visit for chest pain evaluation (P < 0.001). There was a significant reduction in the number of prescriptions written for topical and oral nitrates (32% precatheterization vs. 5% postcatheterization, P < 0.04), but not of beta-blockers (26% vs. 21%, P = 0.53) or calcium blockers (32% vs. 32%, P = 1.0). Furthermore, most of the 21 surviving patients were found subsequently to have a noncardiac basis for their pain: pericarditis was felt to be the cause of chest pain in 4 patients, pulmonary disease in 7 patients, and gastrointestinal conditions in 8 patients. Diagnostic coronary arteriography may identify a subset of patients in whom a finding of noncritical coronary artery disease leads to a reduction in physician visits for evaluation of chest pain syndromes and reduced use of nitrates. In addition, when coronary artery disease is known to be mild, a noncardiac etiology for the chest pain can be sought. These results may decrease the use of expensive medical resources and encourage full occupational and lifestyle rehabilitation.