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In low-risk patients with ACS, noninvasive testing adds little to clinical evaluation
Clinical Question
In patients at low risk who present with symptoms of acute coronary syndrome, does additional noninvasive testing improve short-term outcomes?
Bottom line
In patients with acute chest pain but a normal initial troponin test result and no ischemic electrocardiogram changes, additional stress testing or coronary computed tomographic angiography (CCTA) did not affect the likelihood of eventual percutaneous coronary intervention or major adverse cardiac events over the short term (29 days). 2b
Reference
Study design: Cohort (retrospective)
Funding: Self-funded or unfunded
Setting: Emergency department
Synopsis
This study is a secondary analysis of a randomized multicenter clinical trial enrolling 1000 patients from 9 hospital emergency departments in the United States. The patients were aged 40 to 74 years and presented with symptoms suggestive of acute coronary syndrome but without ischemic electrocardiogram changes or an initial positive troponin test result. All patients were randomly assigned (allocation concealment unknown) to the standard evaluation used at each emergency department, with or without the addition of CCTA. Some patients (n = 455) received functional testing (exercise treadmill, exercise or pharmacological nuclear imaging, or stress echocardiography). The 118 patients (12%) who did not receive either CCTA or functional testing had a shorter length of stay in the emergency department (20.3 vs 27.9 hours; P < .001). Over the subsequent 28 days, rates of eventual percutaneous coronary intervention and major adverse cardiac events were not different, and there were no missed patients with ACS. There are many limitations to this study—eg, lack of randomization to further intervention arm and short follow-up—but a recent network meta-analysis also showed a lack of benefit of CCTA over other functional testing methods (BMJ 2018;360:k504 ! doi: 10.1136/bmj.k504).
Reviewer
Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA
Comments
This study in short version at least says there were no missed cases I believe it indicate noninvasive test is adequate and there is no need for further testing by invasive Coronary angio gram.
and from time spend in Er these were not admitted to hospital ? were these coronary event or just chest pain?
20.7 hours for the "shorter stay" group just for presenting with symptoms suggest of ?? This cannot have been a Canadian study. Do your ECG and high sensitivity trop, if normal repeat after one hour and if still normal -- out the door! (with follow up).
The follow-up got this interesting study is too short.
Good poem
Excellent