Clinical Evaluation Alone in Acute Chest Pain

Study Questions:

What is the incremental benefit of noninvasive coronary testing in patients presenting to emergency departments (EDs) with acute chest pain?

Methods:

This was a non-prespecified secondary analysis of the ROMICAT-II trial. In this study, patients who presented to an ED with acute chest pain, negative biomarkers, and nonischemic electrocardiogram (ECG) were randomized to coronary computed tomography (CT) angiography versus usual care, typically stress testing. A subset of patients, nearly all from the usual care arm, did not undergo noninvasive coronary imaging at the index visit. Propensity weighting was used to generate adjusted estimates of the difference in length of stay (LOS) between clinical evaluation only or clinical evaluation plus noninvasive testing (either coronary CT angiography or stress testing). As secondary endpoints, rates of direct ED discharge, hospital admission, diagnostic testing (coronary CT angiography or stress testing), invasive coronary angiography, percutaneous coronary intervention or coronary artery bypass graft surgery, major adverse coronary events (defined as composite of death, myocardial infarction, unstable angina, urgent revascularization, or repeated ED visit or hospitalization for chest pain). Health care costs were also measured in a subset of patients.

Results:

There were 882 patients who underwent clinical evaluation plus noninvasive imaging and 118 who underwent clinical evaluation alone. Clinical evaluation was associated with significantly lower LOS (20.3 vs. 27.9 hours), but no difference in direct ED discharge of hospitalization. 10% of patients who underwent noninvasive imaging underwent coronary angiography as compared with 0% in the clinical evaluation alone group (p < 0.001) during the index visit. During follow-up, 11% of patients who underwent noninvasive imaging underwent coronary angiography, compared to 2% in the clinical evaluation group (p = 0.008). Noninvasive imaging was associated with percutaneous revascularization during the index visit (4% vs. 0%, p = 0.02). Patients without imaging had more return visits to the ED prior to adjustment (7% vs. 25%, p = 0.047), but not after adjustment (5.8% vs. 2.8%, p = 0.08). Total costs during the study period were lower with clinical evaluation alone ($2,261.50 vs. $2,584.30, p = 0.009). No cases of missed acute coronary syndrome occurred in either group, and major adverse cardiac events were comparable (1% vs. 2%, p = 0.24).

Conclusions:

In patients who present to an ED with acute chest pain, negative biomarkers, and nonischemic ECG, further testing with coronary CT angiography or stress testing was associated with increased LOS and greater costs without better clinical outcomes.

Perspective:

This study is a very important reanalysis of the ROMICAT-II data. It underscores that most patients of the type recruited to ROMICAT-II and similar trials can be discharged safely from the ED if biomarkers and ECG evaluation are reassuring. This is also supported by several studies investigating the utility of troponins for direct ED discharge of patients with acute chest pain. Unfortunately, this was not a part of the trial randomization and patients who did not undergo testing were generally healthier. Consequently, propensity methods were used to adjust for differences in patient characteristics. Although this is a powerful method, it is not able to completely eliminate confounding factors.

Clinical Topics: Acute Coronary Syndromes, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, ACS and Cardiac Biomarkers, Aortic Surgery, Interventions and ACS, Interventions and Imaging, Angiography, Nuclear Imaging

Keywords: Acute Coronary Syndrome, Angina, Unstable, Chest Pain, Coronary Angiography, Biological Markers, Coronary Artery Bypass, Diagnostic Imaging, Electrocardiography, Emergency Service, Hospital, Health Care Costs, Length of Stay, Myocardial Infarction, Myocardial Revascularization, Percutaneous Coronary Intervention, Troponin


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