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Cardiac Testing in Emergency Room Chest Pain Patients
Study Questions:
What is the clinical impact of cardiac testing or coronary angiography in patients who present to the emergency department (ED) with chest pain without initial findings of ischemia?
Methods:
The authors used national claims data (Truven MarketScan) and performed a retrospective cohort analysis using weekday (Monday-Thursday) versus weekend (Friday-Sunday) presentation as an instrument to adjust for unobserved case-mix variation (selection bias) between 2011 and 2012. The primary endpoints were coronary revascularization (percutaneous coronary intervention or coronary artery bypass graft surgery) and acute myocardial infarction (AMI) admission at 7, 30, 180, and 365 days.
Results:
The data included a total of 926,633 privately insured patients ages 18-64 years (mean age, 44 years, 58% female) who presented to the ED with chest pain without an initial diagnosis consistent with acute ischemia. Cardiac testing was performed in 224,973 patients and was more commonly performed in the weekday patients. After risk factor adjustment, testing within 30 days was associated with a significant increase in coronary angiography (36.5 per 1,000 patients tested; 95% confidence interval [CI], 21.0-52.0) and revascularization (22.8 per 1,000 patients tested; 95% CI, 10.6-35.0) at 1 year without a significant change in AMI admissions (7.8 per 1,000 patients tested; 95% CI, −1.4 to 17.0).
Conclusions:
Cardiac testing in patients with chest pain was associated with increased downstream testing and treatment without a reduction in AMI admissions.
Perspective:
Chest pain is the presenting symptom for approximately 6 million ED visits in the United States every year. Most of these patients do not have coronary ischemia, and current guidelines recommend further cardiac testing in appropriately selected patients. This recommendation results in a large number of stress tests or coronary computed tomography angiograms, but the clinical effectiveness of this approach is poorly validated. This study did not find a reduction in hard events with cardiac testing, but it did result in an increase in coronary angiography and revascularizations. Better risk assessment tools are needed to identify patients most likely to benefit from further cardiac imaging.
Keywords: Acute Coronary Syndrome, Angina, Unstable, Chest Pain, Coronary Angiography, Coronary Artery Bypass, Coronary Artery Disease, Emergency Service, Hospital, Exercise Test, Myocardial Infarction, Myocardial Ischemia, Myocardial Revascularization, Percutaneous Coronary Intervention, Risk Assessment, Tomography, X-Ray Computed
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