Emergency cardiac stress testing in the evaluation of emergency department patients with atypical chest pain

doi:10.1016/S0196-0644(05)80793-0

Annals of Emergency Medicine

Volume 22, Issue 5, May 1993, Pages 794-798

https://doi.org/10.1016/S0196-0644(05)80793-0 Get rights and content

Study objectives:

To determine the feasibility, safety, and reliability of emergency cardiac treadmill exercise stress testing (CTEST) in the evaluation of emergency department patients with atypical chest pain.

Design:

Thirty-two patients with atypical chest pain, normal ECGs, and risk factor stratification having low-probability of coronary artery disease were evaluated prospectively using outpatient, emergency CTEST. Study patients were compared with a retrospectively selected sample of admitted patients diagnosed with atypical chest pain who met the study criteria and were evaluated with CTEST as inpatients. All patients had follow-up at three and six months after evaluation.

Setting:

University-affiliated community teaching hospital with 65,000 annual ED visits.

Results:

All patients had normal CTEST. No patient had evidence of coronary artery disease, myocardial infarction, or sudden death during the follow-up period. The average length of stay was 5.5 hours for emergency CTEST patients versus two days for inpatients. The average patient charge was $467 for ED evaluation with emergency CTEST versus $2,340 for inpatient evaluation.

Conclusion:

Emergency CTEST is a safe, efficient, cost-effective, and practical method of evaluating selected ED patients with chest pain. It is a useful aid for clinical decision making and may help to prevent unnecessary hospital admissions.

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Cited by (77)

2015 ACR/ACC/AHA/AATS/ACEP/ASNC/NASCI/SAEM/SCCT/SCMR/SCPC/SNMMI/STR/STS Appropriate Utilization of Cardiovascular Imaging in Emergency Department Patients With Chest Pain: A Joint Document of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Appropriate Use Criteria Task Force
2016, Journal of the American College of Cardiology
Citation Excerpt :
In this situation, stress testing for inducible ischemia or anatomic testing for the presence of CAD are appropriate, with all rest and stress studies as well as CCTA being considered appropriate. For low-risk patients with interpretable electrocardiograms, stress ECG without imaging has been reported to be associated with a decrease in unnecessary admissions (21,76,78,79). The excellent NPV of 98% to 99% has been confirmed, although the PPV is limited for obstructive CAD (80–87).
2015 ACR/ACC/AHA/AATS/ACEP/ASNC/NASCI/SAEM/SCCT/SCMR/SCPC/SNMMI/STR/STS Appropriate Utilization of Cardiovascular Imaging in Emergency Department Patients with Chest Pain :A Joint Document of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Appropriate Use Criteria Task Force
2016, Journal of the American College of Radiology
Identification of very low risk chest pain using clinical data in the emergency department
2011, International Journal of Cardiology
Evaluation of chest pain of uncertain origin in the emergency department is a challenge. Chest pain units, involving non-invasive stress testing, have logistic constraints. Our aim was to identify very low risk patients for early discharge using clinical data.
A total of 772 patients were studied. Ischemia in the electrocardiogram, troponin elevation or history of ischemic heart disease, were exclusion criteria. The primary end point was 30 day cardiac events (death, myocardial infarction or revascularization). The secondary end point was 1 year major events (death or myocardial infarction).
The primary and secondary end point rates were 123 (18%) and 31 (4%). Predictive variables for the primary end point were typical chest pain (OR = 1.8, p = 0.007), ≥2 pain episodes in last 24 h (OR = 3.4, p = 0.0001), age ≥ 55 years (OR = 1.8, p = 0.03), male (OR = 2.2, p = 0.001), diabetes (OR = 1.8, p = 0.01) and family history of ischemic heart disease (OR = 2.0, p = 0.02). A very low risk category could be distinguished (< 2 predictors, n = 114) that showed only 3 (2.6%) events at 30 days (all 3 revascularizations), compared with 120 (18%) in the remaining patients (p = 0.0001). The very low risk criteria had 97% negative predictive for 30 day cardiac events. No very low risk patient presented major events at 1 year compared with 31 (4.7%) in the remaining patients (p = 0.009).
In patients presenting to the emergency department with chest pain of uncertain origin and without prior ischemic heart disease, very low risk patients can be identified using clinical data. These patients could be quickly discharged without further non-invasive stress testing.
Efficacy of coronary revascularization in patients with acute chest pain managed in a chest pain unit
2009, Mayo Clinic Proceedings
To investigate the safety of discharge of patients deemed at low risk of cardiac events after evaluation in a chest pain unit and to determine the prognostic effect of revascularization of patients deemed at high risk.
The study population consisted of 1088 patients presenting at the emergency department from January 15, 2001, to September 1, 2006, with chest pain but without ischemia on electrocardiography or troponin elevation. Patients were managed by a chest pain unit protocol that included early exercise testing. Three groups of patients were distinguished: (1) those discharged after exercise testing (424 [39%]); (2) those in whom unstable angina was ruled out after in-hospital evaluation (208 [19%]); and (3) those in whom unstable angina was confirmed or not ruled out (456 [42%]). Of the 456 patients in group 3, 183 (40%) were revascularized at the index episode. The primary end point was the occurrence of myocardial infarction or death within 1 year. Adjustments were made for patient characteristics and a propensity score for revascularization (c statistic [0.83]).
Groups 1 and 2 showed lower rates of the primary end point than group 3 (group 1: 7 [1.7%]; group 2: 1 [0.5%]; group 3: 62 [13.6%]; P=.001). In group 3, revascularization at the index episode did not reduce the primary end point in the univariate (22 [12%] vs 29 [11%]; P=.80) and multivariate (hazard ratio, 1.4; 95% confidence interval, 0.7-2.5; P=.40) analyses. In-hospital revascularization decreased the need for postdischarge revascularization (hazard ratio, 0.3; 95% confidence interval, 0.1-0.7; P=.01).
Chest pain unit protocols are associated with safe patient discharge. Although early revascularizations may decrease the need for postdischarge revascularizations, they may not improve 1-year outcomes by reducing the number of myocardial infarctions or deaths.
Acute cardiac ischemia time-insensitive predictive instrument predicts exercise treadmill test results in the chest pain unit
2006, American Journal of Emergency Medicine
An evaluation of emergency physician selection of observation unit patients
2006, American Journal of Emergency Medicine
Appropriate patient selection is critical for maximal observation unit (OU) effectiveness. We hypothesized emergency physicians underuse the OU for admitted patients and overuse the OU for patients who would otherwise be discharged.
Treating emergency physicians were asked about patient suitability for admission to an OU at a busy, urban, academic emergency department (ED) as part of a prospective cohort study of ED patients who were admitted or had an ED length of stay exceeding 4 hours. The OU was closed for renovation during the 2-month study, so physician opinion could be compared with patient course in the absence of observation services. Two blinded emergency physicians reviewed charts using structured forms and explicit definitions to determine actual patient course. Hospitalized patients were considered potential OU candidates according to a priori criteria: (1) hospital length of stay less than 48 hours, (2) no procedure or diagnosis requiring hospitalization, and (3) no death.
Of 1747 enrolled patients, 131 were excluded with incomplete data. Median age was 45 years. Patients were 40% white and 48% men. Emergency physicians identified 363 (23%) patients as observation candidates. Of these, 182 (50%) were actually discharged directly. The remaining 181 (50%) were hospitalized; 101 (56%) were observation candidates based on chart review. Of 799 admitted patients not selected for observation, 232 (29%) were suitable for observation by chart review.
Selection of patients for observation was suboptimal; emergency physicians routinely identified patients as OU candidates who were not ultimately admitted, and they missed many admitted patients who might have been appropriate OU candidates. Both over- and underuse should be addressed to maximize the effectiveness of OUs.

View all citing articles on Scopus

: This study was supported by a grant from the Akron City Hospital Foundation.

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Original contributionEmergency cardiac stress testing in the evaluation of emergency department patients with atypical chest pain

Study objectives:

Design:

Setting:

Results:

Conclusion:

Am J Emerg Med

Mayo Clin Proc

J Am Coll Cardiol

J Psychosomat Res

Mayo Clin Proc

Ann Emerg Med

Ann Emerg Med

Mayo Clin Proc

Am J Emerg Med

Prog Cardiovasc Dis

Am J Med

Am J Emerg Med

Chest

Self-administration of a questionnaire on chest pain and intermittent claudication

Br J Prevent Soc Med

Causes of chest pain in patients with normal coronary arteries: The eye of the beholder

Am J Cardiol

Atypical or nonanginal chest pain

Arch Intern Med

Acute chest pain without obvious cause before the age of 40

Acta Med Scand

Clinical diagnosis of nonanginal chest pain: The differentiation of angina from nonanginal chest pain by history

Clin Cardiol

Original contribution
Emergency cardiac stress testing in the evaluation of emergency department patients with atypical chest pain