Conservative management VS. exercise testing in patients with acute chest pain and non-elevated troponin: a randomized clinical trial

Introduction Acute chest pain is a common reason for emergency department (ED) attendance. In patients with suspected acute coronary syndrome (ACS) but non-ischaemic electrocardiogram (ECG) and non-elevated high-sensitivity cardiac troponin (hs-cTn), the optimal diagnostic approach remains uncertain. European guidelines support further non-invasive testing, whereas American recommendations suggest that additional testing may be unnecessary in selected low-risk patients. Randomised evidence in the hs-cTn era is limited. Purpose To determine whether exercise testing provides clinical benefit compared with a conservative diagnostic strategy based on clinical assessment in patients with acute chest pain, non-elevated hs-cTn and non-ischaemic ECG. Methods This prospective, single-centre, exploratory randomised controlled trial (1:1 allocation) enrolled adults presenting to the ED with non-traumatic chest pain within 24 hours of symptom onset between May 2019 and December 2024. Eligible patients had a non-ischaemic ECG and negative or inconclusive serial hs-cTnI (defined as <5 ng/L or a 0/3-hour delta <3 ng/L, with all values below the 99th percentile). Key exclusion criteria were typical angina, known coronary artery disease, left ventricular ejection fraction <40%, severe valvular disease, or an alternative confirmed diagnosis.The primary endpoint was a composite of major adverse cardiovascular events (MACE): cardiovascular death, non-fatal myocardial infarction, unstable angina requiring hospitalisation, or coronary revascularisation, assessed at 30 days, 3 months and 6 months. Secondary endpoints included index admission, additional cardiovascular testing (index visit or follow-up), ED reattendance for chest pain, and individual MACE components. Results A total of 153 patients were included (figure 1). Baseline clinical characteristics of the two groups are described in table 1. No MACE occurred in either group during 6-month follow-up. ED reattendance was low and similar between groups (2.6% vs 4.0%, p=0.68). In the intervention arm, 39% underwent exercise echocardiography and 92.2% of tests were negative; two false positives were identified. Four patients underwent additional testing at the index visit, and two required hospitalisation for coronary angiography. Additional downstream testing during follow-up was infrequent and similar between the groups (0% vs 4%, p=0.12). All final diagnoses were non-cardiac chest pain. Conclusion In low-risk patients with acute chest pain, non-ischaemic ECG and non-elevated hs-cTn, no major cardiovascular events were observed at 6 months. Routine exercise testing did not improve outcomes compared with a conservative approach. Larger studies are required to confirm these findings.