Routine Testing of Patients With Chest Pain Might Not Be Efficient

Routine testing of patients who presented to emergency departments with chest but without evidence of ischemia was associated with increased resource utilization but not with improved outcomes, according to a recent study.

In their retrospective cohort study, the researchers analyzed data from 926,633 privately insured patients from 18 to 64 years of age who presented to an emergency department with chest pain but were not initially diagnosed with acute ischemia. Patients included in the analysis underwent noninvasive imaging or coronary angiography within 2 days or 30 days after presentation. In addition, the researchers used weekday vs weekend presentation as an instrument to adjust for unobserved case-mix variation.

Coronary revascularization, including percutaneous coronary intervention or coronary artery bypass graft surgery, and acute myocardial infarction (AMI) at 7 days, 30 days, 180 days, and 1 year after presentation were assessed as the primary outcomes. Secondary outcomes included coronary angiography and coronary artery bypass grafting among those who underwent angiography.

Of the 926,633 patients, 224,973 received testing and 701,660 did not receive testing. Those who received testing were found to have an increased risk at baseline for AMI and greater risk of AMI admission compared with those who did not receive testing.

Patients who presented with chest pain on weekdays had similar baseline comorbidities as weekend patients but were more likely to receive testing.

After adjusting for risk factors, the researchers found that testing that occurred within 30 days after presentation was associated with a significant increase in coronary angiography and revascularization at 1 year, with 36.5 cases per 1000 patients tested and 22.8 cases per 1000 patients tested, respectively. However, there were no significant changes in AMI admissions.

Likewise, testing within 2 days was associated with a significant increase in revascularization, but no differences in AMI admissions.

“Cardiac testing in patients with chest pain was associated with increased downstream testing and treatment without a reduction in AMI admissions, suggesting that routine testing may not be warranted,” the researchers concluded. “Further research into whether specific high-risk subgroups benefit from testing is needed.”

—Melissa Weiss

Reference:

Sandhu AT, Heidenreich PA, Bhattacharya J, Bundorf K. Cardiovascular testing and clinical outcomes in emergency department patients with chest pain. JAMA Intern Med. 2017;177(8):1175-1182. doi:10.1001/jamainternmed.2017.2432.