In the evaluation of patients with low-risk chest pain, there has been a rise in the deferral of further testing, with lower rates of functional testing and invasive coronary angiography (ICA), and significant variation at the site level in the proportion of patients who underwent further noninvasive testing, according to a recent study published in JACC: Cardiovascular Imaging.

Using data from ACC's Chest Pain – MI Registry, Riyad Yazan Kherallah, MD, et al., included 167,220 patients from 327 sites admitted with troponin-negative chest pain between Jan. 1, 2019, and March 31, 2023. Seeking to explore trends in evaluation strategies before and after the release of the 2021 ACC/AHA Chest Pain Guideline, patients were stratified by initial ischemic evaluation, including ICA, noninvasive anatomical (coronary computed tomography angiography [CCTA]), noninvasive functional, or no further testing.

Overall, 11.2% of patients underwent ICA as initial testing strategy; 20.5% underwent anatomical or functional noninvasive testing (8.8% of which were for CCTA); and 68.2% had no further testing. The authors note an increase in deferral of further testing from 57.6% in the first quarter of 2019 to 72.6% in the first quarter of 2023 (trend p<0.0001), with rates of functional testing and ICA both decreasing over the course of the study period. In patients who underwent further testing, the rate of coronary CTA increased from 6.2% to 12%, "predominately because of decline in functional testing rather than an increase in the absolute number of coronary CTAs performed."

In addition, significant site-level variation was observed in the proportion of patients who underwent further noninvasive testing vs. no further testing (MOR, 2.95 [95% CI, 2.49-3.79]; adjusted MOR, 2.83 [95% CI, 2.40-3.6]) as well as in the utilization of CCTA in patients who underwent additional noninvasive testing. "The low utilization of coronary CTA (just 1.8% of the overall cohort) represents a missed opportunity for health care systems," write the authors.

"The observed rise in deferral of further testing occurred with increased adoption of high-sensitivity troponin and faster rule out clinical decision pathways, alongside updates in professional guidelines," note Kherallah and colleagues. "It has implications for delivery of health care, clinical throughput and health care costs."