Original Investigation |

Yield of Routine Provocative Cardiac Testing Among Patients in an Emergency Department–Based Chest Pain Unit

Luke K. Hermann, MD; David H. Newman, MD; W. Andrew Pleasant, MD; Dhanadol Rojanasarntikul, MD; Daniel Lakoff, MD; Scott A. Goldberg, MD; W. Lane Duvall, MD; Milena J. Henzlova, MD
JAMA Intern Med. 2013;173(12):1128-1133. doi:10.1001/jamainternmed.2013.850.
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Importance The American Heart Association recommends routine provocative cardiac testing in accelerated diagnostic protocols for coronary ischemia. The diagnostic and therapeutic yield of this approach are unknown.

Objective To assess the yield of routine provocative cardiac testing in an emergency department–based chest pain unit.

Design and Setting We examined a prospectively collected database of patients evaluated for possible acute coronary syndrome between March 4, 2004, and May 15, 2010, in the emergency department–based chest pain unit of an urban academic tertiary care center.

Participants Patients with signs or symptoms of possible acute coronary syndrome and without an ischemic electrocardiography result or a positive biomarker were enrolled in the database.

Exposures All patients were evaluated by exercise stress testing or myocardial perfusion imaging.

Main Outcomes and Measures Demographic and clinical features, results of routine provocative cardiac testing and angiography, and therapeutic interventions were recorded. Diagnostic yield (true-positive rate) was calculated, and the potential therapeutic yield of invasive therapy was assessed through blinded, structured medical record review using American Heart Association designations (class I, IIa, IIb, or lower) for the potential benefit from percutaneous intervention.

Results In total, 4181 patients were enrolled in the study. Chest pain was initially reported in 93.5%, most (73.2%) were at intermediate risk for coronary artery disease, and 37.6% were male. Routine provocative cardiac testing was positive for coronary ischemia in 470 (11.2%), of whom 123 underwent coronary angiography. Obstructive disease was confirmed in 63 of 123 (51.2% true positive), and 28 (0.7% overall) had findings consistent with the potential benefit from revascularization (American Heart Association class I or IIa).

Conclusions and Relevance In an emergency department–based chest pain unit, routine provocative cardiac testing generated a small therapeutic yield, new diagnoses of coronary artery disease were uncommon, and false-positive results were common.

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Figure. Number of stress tests and percentage with positive results by age range.





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Approximately 8% of screened patients benefited
Posted on July 3, 2013
David L. Keller, M.D.
Providence Medical Group
Conflict of Interest: None Declared
Hermann and colleagues conclude that "only 0.7% of patients who underwent stress testing ultimately had findings consistent with a potential benefit from revascularization" (1). This dismal tally omits a large group of patients who benefited in other ways. 11.2% of stress-tested patients had studies positive for inducible myocardial ischemia; of those who were catheterized, 25% had normal coronary arteries, while 75% had some degree 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 initiated on appropriate medical therapy. The value of statin therapy to lower LDL cholesterol, plus low-dose aspirin, is well-established in such patients, and would not be particularly harmful to the 2.8% (25% of 11.2%) of patients who had false-positive stress tests. This study demonstrated that about 8.3% of chest pain patients given stress tests in the E.R. were accurately diagnosed with coronary atherosclerotic disease, so that potentially life-saving therapy with aspirin and a statin could be started immediately. A patient does not have to undergo revascularization to benefit from a stress test.
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