Paper Raises Doubts About Need for Further Testing After Resolved Chest Pain

Patients who present to the emergency department with an episode of resolved chest pain and no electrographic or biomarker abnormalities are at low enough risk for a cardiac event that they probably do not need further testing, according to an article published online September 17, 2012, ahead of print in the Archives of Internal Medicine. The suggestion goes against current American College of Cardiology/American Heart Association guidelines.

Those guidelines, published in 2010, recommend that if ACS is excluded and chest pain does not recur, patients should undergo further risk stratification with noninvasive tests such as exercise or chemical stress testing or coronary computed tomographic (CT) angiography. Routine noninvasive testing is intended to further reduce the likelihood that the patient had or will have an acute MI.

But Vinay Prasad, MD, of Northwestern University (Chicago, IL), and colleagues say following those guidelines does not necessarily lead to better outcomes—even when a stress test is positive—and may actually contribute to overdiagnosis of cardiovascular disease.

Testing Linked to Overdiagnosis

“The inciting pain may have been noncardiac, yet it prompted a cascade of events that led to the diagnosis of CAD and revascularization of asymptomatic lesions,” they write. “Other patients may have had angina and significant coronary lesions, but landmark randomized trials have shown that medical management is the best initial strategy for most such patients.”

To support this position, the authors cite a recent study (Litt HI. N Engl J Med. 2012;366:1393-1403) showing that use of noninvasive CT angiography “led to a diagnosis of CAD and revascularization at 3-fold the rate of usual care,” yet did not improve outcomes. Two other randomized trials that involved stress testing of intermediate- or high-risk patients, DIAD and DECREASE II, also found no improvement in rates of short- or long-term cardiac death and MI, they add.

In fact, Dr. Prasad and colleagues say no trial to date has examined the specific question of whether additional testing really does enhance outcomes in patients with an episode of resolved chest pain.

For this reason, they propose randomized trials to compare routine stress testing and/or CT angiography to a strategy of no further intervention in patients with isolated chest pain and no ECG or biomarker abnormalities.

According to the authors, their argument is strengthened by a recent study showing that stress testing can be reduced by nearly half without any change in outcomes (Napoli AM. Crit Pathw Cardiol. 2012;11:26-31). However, Dr. Prasad and colleagues fail to mention that this study took place in a dedicated chest pain unit staffed with joint emergency medicine and cardiology staff; therefore the findings may not hold true in everyday practice.

How Is No Testing Better?

In a telephone interview with TCTMD, Matthew J. Budoff, MD, of Harbor-UCLA Medical Center (Torrance, CA), said Dr. Prasad and colleagues make a “circular” argument that is without rationale.

While they make a case for eliminating further testing, he said, the authors begin the article by stating that the goal of current practice is to reduce the risk of missing an MI—a major source of lawsuits filed against emergency department physicians—and reassure patients that they are at low risk for a future event.

“How would not testing resolve the issue of malpractice or reassurance?” Dr. Budoff asked. “Proposing to do no testing can only lead to more missed cases, not less. They provide no rationale for how we would avoid missing ACS and safely send home patients.”

However, the authors do observe that the frequently cited 2% incidence of inappropriate discharge of chest pain patients from the emergency department is based on 2-decade-old data before routine use of biomarker testing. “Thus, the historical circumstances that provide impetus for our current practice may no longer be applicable,” they write.

Dr. Budoff said that a randomized trial such as the one proposed by Dr. Prasad and colleagues is not only counterintuitive but also essentially unethical. “There is no plausibility that anyone would undertake a study in which patients were randomized to no risk-stratification at all,” he commented. “They’re not even suggesting any solutions other than doing less. You can’t just send people home on a whim.”

Furthermore, Dr. Budoff pointed out, at least 3 randomized trials have shown that the use of CT angiography in the emergency department is safe and effective and leads to faster discharge. The trials also have demonstrated the cost-effectiveness of coronary CT angiography compared with treadmill or stress nuclear imaging tests, he added.

“To me, this article is more of an opinion piece than a scientific review,” Dr. Budoff concluded, “since they picked and chose a few studies that made their point but left out many others in the published literature showing good evidence that [CT angiography] is one of the best modalities we have.”

 


 

Source:Prasad V, Cheung M, Cifu A. Chest pain in the emergency department: The case against our current practice of routine noninvasive testing. Arch Intern Med. 2012;Epub ahead of print.

 

 

Disclosures
  • Dr. Prasad reports no relevant conflicts of interest.
  • Dr. Budoff reports receiving a research grant from GE Healthcare.

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