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Additional testing of limited benefit in patients with new-onset chest pain
Clinical Question
In patients who present to an emergency department with chest pain and a normal initial work-up, does additional testing improve clinical outcomes?
Bottom line
An electrocardiogram that does not show ischemic changes plus a negative troponin test result in middle-aged patients with new-onset chest pain might be enough to rule out acute coronary syndrome. In this study (which was not randomized), additional testing with angiography or stress testing diagnosed acute coronary syndrome in more people but did not improve short-term outcomes. 2b
Reference
Study design: Cohort (retrospective)
Funding: Self-funded or unfunded
Setting: Emergency department
Synopsis
This analysis was a post-hoc analysis of the Rule Out Myocardial Ischemia/Infarction by Computer Assisted Tomography II study, which aimed to determine the usefulness of cardiac computed tomographic angiography (CCTA) to rule out acute coronary syndrome in patients presenting with a clinical evaluation that suggests it. The investigators enrolled 1000 patients aged 40 years to 74 years (average age 53.2 years) in 1 of 9 emergency departments in the United States with symptoms (chest pain, epigastric/jaw/shoulder pain, shortness of breath) suggestive of acute coronary syndrome but without ischemic changes on electrocardiogram or a positive troponin test result. The patients were randomized to receive either CCTA or usual care; all but 118 patients (88%) received some sort of additional cardiac testing during the initial emergency department evaluation (CCTA or stress testing). As one might guess, patients who did not receive additional cardiac testing spent somewhat less time in the emergency department and had overall fewer diagnostic tests. They also were less likely to be given a diagnosis of acute coronary syndrome (0% vs 9%; number needed to treat [NNT] = 11), less likely to have angiography (2% vs 11%; NNT = 11) and less likely to have a percutaneous coronary intervention (0% vs 10%; NNT = 10). In the first 28 days after presentation, there was no difference between the 2 groups in rates of coronary interventions, return emergency department visits, or major adverse cardiac events. It's time for a randomized controlled trial to test whether a normal electrocardiogram and negative troponin test result is sufficient to send home relatively young people with chest pain.
Reviewer
Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA
Comments
need to know more
My patient population is a bit older, but we do see the same thing some times.
The ECG and troponin both being normal is often quite rare.
The sensitivity of the newer tests is quite amazing and we rarely see totally normal values in more complicated and frail people so ones who are younger and less complicated should be good with normal values.
In my experience, stress tests are often moved to quite quickly for the purposes of ruling out cardiac, helping to reassure the patient and also for rapid disposition...do we do too many?
I think that it would be good to have a study to look at that which the author comments on - who can we be less aggressive in?
Good poem
bad poem
Not new
We send people with normal ECGs and trops home from ER all the time??? This seems to talk way more about the American approach.
This shows the American approach to over investigation instead of proper education at the time of discharge. How much money was wasted when a few weeks of appropriate waiting would have revealed those at increased risk of ACS.
Don't forget the differential diagnosis of chest pain can also include a dissecting aortic aneurysm. After ECG and troponin, consider a chest x-ray to see if the mediastinum is widened when a "pink lady" did not relieve the symptoms at this point. Some years ago I had just the case and a patient was sent from our smaller hospital after CXR, to Edmonton and undergone surgery for aneurysm that night.
I love how the study indicates these are middle aged when the study includes up to 74 years old!