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CT scans, cardiac stress tests offer no benefit to patients with chest pain in ED

Noninvasive assessments with coronary CT angiography or stress tests are often unnecessary and overused in patients presenting to the ED with chest pain, providing no clinical benefit and increasing health care costs, according to a new study published in JAMA Internal Medicine and presented at the American Heart Association’s Scientific Sessions.

“Approximately 10 million patients present to [EDs] in the United States annually with chest pain suggestive of an [acute coronary syndrome], presenting a frequent challenge to ED physicians,” Samuel W. Reinhardt, MD, from the department of internal medicine at Washington University School of Medicine, St. Louis, and colleagues wrote.

Reinhardt and colleagues analyzed data from the Rule Out Myocardial Ischemia/Infarction by Computer Assisted Tomography (ROMICAT-II) trial to determine if noninvasive testing plus clinical evaluation improves outcomes in patients presenting to the ED with acute chest pain compared with clinical evaluation alone. Noninvasive testing included coronary CT angiography or stress testing, while clinical evaluation included a medical history and physical examination, an ECG and biomarker assessment.

The researchers found that of the 1,000 patients from the ROMICAT-II trial, 12% (mean age, 53.2 years; 42% female) underwent clinical evaluation without noninvasive testing and 88% (mean age, 54.4 years; 48% female) underwent coronary CT angiography or stress testing. Baseline characteristics and clinical presentation did not differ between groups.

Over the course of the 28-day study period, clinical evaluation alone was associated with a shorter length of stay (20.3 vs. 27.9 hours; P < .001), reduced rates of diagnostic testing (P < .001) and angiography (2% vs. 11%; P < .001), decreased median costs ($2,261.5 vs. $2,584.3; P = .009) and less cumulative exposure to radiation (0 vs. 9.9 mSv; P < .001).

Lower acute coronary syndrome diagnosis rates (0% vs. 9%; P < .001) and less coronary angiography (0% vs. 10%; P < .001) and percutaneous coronary intervention (0% vs. 4%; P = .02) were observed in patients who lacked testing in the index visit.

During the 28-day follow-up period, rates of percutaneous coronary intervention (2% vs. 5%; P = .15), coronary artery bypass surgery (0% vs. 1%; P = .61), return ED visits (5.8% vs. 2.8%; P = .08) or major adverse cardiac events, such as MI, unstable angina or death (2% vs. 1%; P = .24) did not differ among groups.

“Our study suggests that in the [ED], stress testing and CT scans are unnecessary for evaluating chest pain in possible heart attack patients,” David L. Brown, MD, senior author of the study from the cardiovascular division at the Washington University School of Medicine, said in a press release. “Patients don’t do any better when given these additional tests. Our study is not a definitive randomized clinical trial, but it does suggest that we are over-testing and over-treating these patients.” – by Alaina Tedesco

Disclosure: The authors report no relevant financial disclosures.