Real-world diagnostic yield of inpatient stress testing after negative serial troponins: A large community hospital cohort study

Study objective: To evaluate the clinical utility and positivity predictors of inpatient stress testing (iST) in a real-world cohort of troponin-negative patients. Design: Retrospective cohort. Setting: Large community hospital in Midwest, USA. Participants: Adults with suspected coronary ischemia who had negative serial troponins and underwent iST during the index admission. Interventions: iST, and downstream interventions. Main outcomes measures: iST positivity and its clinical predictors, its diagnostic performance against invasive coronary angiography (ICA), revascularization rates, and 90-day outcomes. Results: Among 769 patients, iST positivity was 9.4%. Presenting symptoms, and most traditional cardiovascular risk factors were not independently associated with iST positivity. However, established atherosclerotic cardiovascular disease was associated with a higher likelihood of a positive iST (p = 0.03). Among the selectively referred subgroup undergoing ICA, iST demonstrated moderate sensitivity (77.1%) but poor specificity (47.4%) for obstructive coronary artery disease (CAD), with limited discriminatory ability (AUC = 0.62). The negative likelihood ratio (0.48) indicated only modest reduction in post-test probability following a negative iST. Revascularization occurred in 42.1% of ST-positive patients referred for ICA and 20.0% of ST-negative patients. At 90 days, major adverse cardiovascular events were rare (0.7%) across the cohort. Conclusion: Among troponin-negative patients, presenting symptoms and traditional cardiovascular risk factors did not predict iST positivity, with iST demonstrating low diagnostic yield and poor discrimination for obstructive CAD. Overall, these findings suggest that routine reflexive iST in this population may provide limited incremental diagnostic value within this clinical pathway. However, as a retrospective study with clinician-driven referrals, these findings show associations, not causation.