Key result
Clinical risk stratification identified patients without high-risk features who had a low annualized event rate of 0.5%, indicating noninvasive CAD testing is not warranted in this group.
Why the study?
Does routine noninvasive testing improve clinical outcome prediction in low-risk patients admitted with acute chest pain?
Cohort (n=459)
Does routine noninvasive testing improve clinical outcome prediction in low-risk patients admitted with acute chest pain?
Clinical risk stratification effectively identifies low-risk patients with acute chest pain who have a very low event rate, suggesting routine noninvasive testing is not warranted in this group.
May support deferring noninvasive testing in clinically low-risk acute chest pain; leaves open confirmation via randomized trials before practice change.
BACKGROUND: Chest pain decision unit (CDU) evaluation of patients with acute chest pain (ACP) and nondiagnostic electrocardiogram (ECG) usually includes noninvasive testing for coronary artery disease (CAD). HYPOTHESIS: CAD evaluation will not improve clinical outcome in low-risk ACP patients. METHODS: We studied 459 adults admitted to CDU with ACP and no troponin release who underwent noninvasive CAD testing (stress testing in 396 and coronary computed tomographic angiography in 63). Multivariate logistic regression was used to determine predictors of adverse outcome over a 3-year follow-up period. RESULTS: Initial noninvasive test was normal in 367 (80%) and abnormal (positive or indeterminate) in 92 (20%). A total of 42 (9%) patients underwent invasive coronary angiography, and 16 (3.5%) underwent revascularization. During follow-up, 33 patients had a total of 36 major clinical events: 12 revascularizations, 9 myocardial infarctions, and 15 deaths. Multivariate logistic regression analysis identified abnormal ECG (odds ratio [OR]: 2.7, P = 0.03), typical chest pain (OR: 3.8, P = 0.002), diabetes (OR: 4.1, P = 0.001), and known CAD (OR: 2.3, P = 0.03) as independent predictors for adverse outcome, but not noninvasive test result. Thus, in 187 patients with no high-risk features (41% of the cohort), the annualized event rate was 0.5%. In 272 patients with at least 1 high-risk feature, annualized event rates were 2.8% and 5.7% when noninvasive test was normal or abnormal, respectively (P = 0.04). CONCLUSIONS: Clinical risk stratification allows identification of patients at low risk of adverse outcome over an intermediate period of follow-up. Noninvasive testing is not warranted in such patients.
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Cotarlan et al. (2013) conducted a cohort in Acute chest pain with nondiagnostic ECG and no troponin release (n=459). Noninvasive CAD testing vs. Clinical risk stratification was evaluated on Adverse outcome (revascularization, myocardial infarction, or death). Clinical risk stratification identified patients without high-risk features who had a low annualized event rate of 0.5%, indicating noninvasive CAD testing is not warranted in this group.
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