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Defensive Medicine—Legally Necessary but Ethically Wrong?  Inpatient Stress Testing for Chest Pain in Low-Risk Patients

Allen Kachalia, MD, JD; Michelle M. Mello, JD, PhD
JAMA Intern Med. 2013;173(12):1056-1057. doi:10.1001/jamainternmed.2013.7293.
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Ms Perry is a 58-year-old woman who presents to the emergency department with nonexertional substernal chest pain. She has no shortness of breath or other worrisome symptoms. The pain has been intermittent over several years, and last year, findings of treadmill stress testing for the identical symptoms were negative for ischemia.

The resident physician talks with Ms Perry's primary care physician and reviews her records. Judging by her history and presentation, the resident considers Ms Perry to be at very low risk for cardiac ischemia. Consequently, he believes that she does not need further evaluation. The emergency department attending, however, recommends overnight observation and nuclear stress testing. “She may not need it, but treadmill stress tests aren't always accurate, and being wrong is not the worth the risk of getting sued,” she remarks. Ms Perry is admitted; test findings are negative; and she is discharged home.

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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Submit a Comment
The true yield of cardiac testing was 8.3%, not 0.7%
Posted on June 27, 2013
David L. Keller, M.D.
Providence Medical Group
Conflict of Interest: None Declared
It is misleading to quote the results of the study by Hermann and colleagues as "only 0.7% of patients who underwent stress testing ultimately had findings consistent with a potential benefit from revascularization."  This ignores the fact that 11.2% of these patients had studies positive for inducible myocardial ischemia; of those who subsequently had coronary angiograms, 25% had clean coronaries and 75% had evidence of coronary atherosclerotic disease, either obstructive or nonobstructive  Therefore, we can estimate that 8.3% (75% of 11.2%) of the patients who had stress testing performed were accurately diagnosed with coronary artery atherosclerotic disease and immediately initiated on potentially life-saving medical therapy.  The value of treatment with aspirin and a statin is well-established in such patients.  In addition, these patients gained by being assigned to the care of a cardiologist to follow up their new diagnosis of coronary artery disease and to help monitor them for future worrisome symptoms and educate them regarding beneficial lifestyle changes. Add in the peace of mind these patients gained by receiving a timely diagnosis for their chest symptoms, and I would say that the cardiac testing was well-justified by the true positive yield of 8.3%.  A patient does not have to undergo revascularization to benefit from a stress test.
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