Does Noninvasive Cardiac Testing Benefit Patients With Chest Pain?

Noninvasive testing to rule out acute coronary syndrome (ACS) does not appear to benefit clinical outcomes in low-risk and intermediate-risk patients who present with chest pain, according to a recent study.

For their retrospective study, the researchers analyzed data from the Rule Out Myocardial Ischemia/Infarction by Computer Assisted Tomography trial. The trial included 1000 patients who presented with chest pain at 9 emergency departments (ED) and underwent either clinical evaluation alone or clinical evaluation with noninvasive testing, including coronary computed tomographic angiography (CCTA) or stress testing.
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The researchers assessed the patients’ length of stay (LOS) as the primary outcome. Secondary outcomes included hospital admission, costs, direct ED discharge, downstream testing, invasive coronary angiography rates, revascularization, major adverse cardiac events (MACE), and repeated ED visits or hospitalization for recurrent chest pain at 28 days. In addition, the researchers evaluated missed ACS and cumulative radiation exposure as safety endpoints.

Overall, 882 patients (88%) underwent CCTA or stress testing and 118 patients (12%) did not undergo noninvasive testing. The researchers did not find any differences in baseline characteristics or clinical presentation between groups.

Clinical evaluation alone was associated with shorter LOS, lower rates of diagnostic testing and angiography, lower median costs, and less cumulative radiation exposure. Compared with patients who underwent noninvasive testing, those who did not undergo testing had lower rates of ACS diagnosis (9% vs 0%, respectively) and less coronary angiography (10% vs 0%) and percutaneous coronary invention during the index visit (0% vs 4%).

However, there were no differences between clinical evaluation alone and noninvasive testing in the rates of percutaneous coronary invention (2% vs 5%, respectively), coronary artery bypass surgery (0% vs 1%), return ED visits (5.8% vs 2.8%), or MACE (2% vs 1%) during the 28-day follow-up period.

“In patients presenting to the ED with acute chest pain, negative biomarkers, and a nonischemic [Electrocardiography] result, noninvasive testing with CCTA or stress testing leads to longer LOS, more downstream testing, more radiation exposure, and greater cost without an improvement in clinical outcomes,” the researchers concluded.

—Melissa Weiss

Reference:

Reinhardt SW, Lin C, Novak E, Brown DL. Noninvasive cardiac testing vs clinical evaluation alone in acute chest pain: a secondary analysis of the ROMICAT-II randomized clinical trial [published online November 14, 2017]. JAMA Intern Med. doi:10.1001/jamainternmed.2017.7360.