Cardiovascular Testing and Clinical Outcomes in Emergency Department Patients with Chest Pain: Sandhu AT, Heidenreich PA, Bhattacharya J, et al. JAMA Intern Med. 2017;177(8):1175-1182

Abstract

Chest pain remains one of the most common chief complaints in emergency departments (ED) across the United States. In patients with an initial evaluation demonstrating no evidence of acute ischemia, further non-invasive cardiac testing for inducible ischemia is recommended by the American Heart Association. Previous research has demonstrated that this non-invasive testing frequently leads to further invasive testing without clear evidence of a reduction in acute myocardial infarctions (AMI) or other patient-centered outcomes. This study sought to evaluate whether non-invasive testing in patients presenting to an ED with chest pain and no evidence of ischemia on initial evaluation was associated with a change in the rates of AMI admission or revascularization procedures. This retrospective cohort study included 926,633 patients between ages 18 and 64 with an ED diagnosis of chest pain without initial findings of ischemia who underwent cardiovascular testing within 2 to 30 days of the initial ED visit. Cardiovascular testing included non-invasive cardiac testing (exercise electrocardiogram, stress echocardiography, nuclear stress test, coronary computed tomographic angiography) as well as coronary angiography. The cohort was analyzed using multivariable logistic regression. Primary outcomes were coronary revascularization (percutaneous coronary intervention or coronary artery bypass graft surgery) and AMI admissions at 7, 30, 180, and 365 days. After adjusting for observable risk factors, testing 1000 patients within 2 days of the ED visit was associated with 92.1 more coronary angiograms (95% confidence interval (CI) 90.5-93.7) and 11.6 more revascularizations (95% CI 9.4-13.8), but no significant difference in AMI admissions at 1 year (0.1; 95% CI -0.5 to 0.7). Testing within 30 days of presentation was associated with significant increase in angiography, revascularizations and AMI admissions. The authors concluded that while the standard of care in the evaluation of chest pain is risk stratification with non-invasive testing, cardiac testing is associated with increased downstream testing and invasive interventions without a decrease in patient-centered outcomes such as subsequent AMI admission. They suggest a change in how these patients are evaluated, including a shared decision-making model rather than routine cardiac testing. Comment: This study provides evidence for discussion of alternative management strategies in patients with chest pain. With a limited age group and inclusion of only privately insured subjects, generalizability may be affected. The authors acknowledge there are likely untested subgroups that may benefit from further testing. It is also interesting to note the higher rate of invasive testing in patients who presented on weekdays compared to weekends, although AMI admissions were not different between patients presenting on weekdays and weekends. It is not clear from the study whether those patients who received revascularization experienced other positive outcomes, such as improved exercise tolerance or decreased anginal symptoms.