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Routine cardiac testing unnecessary in ED patients with chest pain
Cardiovascular testing in patients with chest pain presenting at EDs did not reduce the rate of acute myocardial infarction admissions or improve patient outcomes, indicating that routine testing may be unnecessary, according to findings published in JAMA Internal Medicine.
“Cardiovascular testing is costly and time-intensive. Moreover, it is unclear whether current practice reduces the risk of future cardiovascular events in patients without evidence of acute ischemia,” Alexander T. Sandhu, MD, MS, from Veterans Affairs Palo Alto Health Care System, and the Center for Health Policy and Center for Primary Care and Outcomes Research at Stanford University, and colleagues wrote. “Past observational analyses have shown that noninvasive testing is associated with large increases in downstream testing and treatment without a reduction in subsequent acute myocardial infarction (AMI) admissions… However, patients who receive testing are higher risk, raising concerns about residual confounding.”
Researchers examined the relationship between cardiovascular testing using noninvasive imaging or coronary angiography, and changes in the rates of coronary revascularization or acute myocardial infarction (AMI) admission in patients presenting to the ED with chest pain. In this retrospective cohort analysis, they compared weekday presentation with weekend presentation between 2011 and 2012 using national claims data that included 926,633 privately insured patients aged 18 to 64 years. They identified patients who underwent noninvasive testing or coronary angiography within 2 days or 30 days of presentation evaluated coronary revascularization (percutaneous coronary intervention or coronary artery bypass graft surgery) and AMI admissions at 7, 30, 180, and 365 days. They also analyzed coronary angiography and coronary artery bypass grafting in patients who received angiography.
Compared with 701,660 patients who did not undergo testing, the 224,973 patients who did had increased risk at baseline and had greater risk of AMI admission (0.35% vs. 0.14% at 30 days). Patients presenting during weekdays (n = 571,988) experienced similar baseline comorbidities when compared with weekend patients (n = 354,645); however, they were more likely to receive testing. After adjusting for risk factors, testing within 30 days was linked to a significant rise in coronary angiography (36.5 per 1,000 patients tested; 95% CI, 21-52) and revascularization (22.8 per 1,000 patients tested; 95% CI, 10.6-35) at 1 year. There was no significant change in AMI admissions for those tested within 30 days (7.8 per 1,000 patients tested; 95% CI, −1.4 to 17). In addition, analysis showed that testing within 2 days was associated with an upsurge in coronary revascularization, but no change in AMI admissions.
“We found that testing was not associated with a reduction in subsequent AMI admissions and further research is needed to evaluate whether a benefit is present in higher risk subgroups,” Sandhu and colleagues wrote. “We believe the current evidence supports a shift in the treatment of these patients; shared decision-making with patients should be considered a viable alternative to routine cardiac testing in the absence of robust evidence to support its benefit.”
In a related invited commentary, Benjamin C. Sun, MD, MPP, from the Center for Policy Research-Emergency Medicine at Oregon Health and Science University, and Rita F. Redberg, MD, MSc, from the division of cardiology at University of California, San Francisco and editor for JAMA Internal Medicine, wrote that these findings challenge the current standard of early noninvasive testing after an ED assessment for potential acute coronary syndrome.
“This clinical strategy is characterized by enormous costs, substantial practice variation, and absence of efficacy data. Moreover, noninvasive testing may expose patients to injuries associated with radiation exposure, invasive angiography, and cardiac revascularization procedures,” Sun and Redberg wrote. “We strongly advocate for randomized clinical studies that will provide definitive guidance for this prevalent, high-risk, and vexing clinical problem.” – by Savannah Demko
Disclosures: The researchers report no relevant financial disclosures. Sun and Redberg report no relevant financial disclosures.