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Original Investigation
June 26, 2017

Cardiovascular Testing and Clinical Outcomes in Emergency Department Patients With Chest Pain

Author Affiliations
  • 1Veterans Affairs Palo Alto Health Care System, Palo Alto, California
  • 2Center for Health Policy and Center for Primary Care and Outcomes Research, Department of Medicine, Stanford University, Stanford, California
  • 3Stanford University School of Medicine, Stanford, California
  • 4Health Research and Policy, Stanford, California
JAMA Intern Med. Published online June 26, 2017. doi:10.1001/jamainternmed.2017.2432
Key Points

Question  In patients who present to the emergency department with chest pain without evidence of ischemia, is cardiac testing—noninvasive testing or coronary angiography—associated with changes in revascularization or acute myocardial infarction (AMI) admissions?

Findings  In a retrospective cohort analysis of 926 633 patients, we used the day of presentation as an instrumental variable to adjust for potential selection bias. Cardiac testing was associated with increased revascularization without a significant change in AMI admissions.

Meaning  Routine testing may increase resource utilization without improving outcomes in patients who present to the emergency department with chest pain without evidence of ischemia.

Abstract

Importance  Noninvasive testing and coronary angiography are used to evaluate patients who present to the emergency department (ED) with chest pain, but their effects on outcomes are uncertain.

Objective  To determine whether cardiovascular testing—noninvasive imaging or coronary angiography—is associated with changes in the rates of coronary revascularization or acute myocardial infarction (AMI) admission in patients who present to the ED with chest pain without initial findings of ischemia.

Design, Setting, and Participants  This retrospective cohort analysis used weekday (Monday-Thursday) vs weekend (Friday-Sunday) presentation as an instrument to adjust for unobserved case-mix variation (selection bias) between 2011 and 2012. National claims data (Truven MarketScan) was used. The data included a total of 926 633 privately insured patients ages 18 to 64 years who presented to the ED with chest pain without initial diagnosis consistent with acute ischemia.

Exposures  Noninvasive testing or coronary angiography within 2 days or 30 days of presentation.

Main Outcomes and Measures  The primary end points were coronary revascularization (percutaneous coronary intervention or coronary artery bypass graft surgery) and AMI admission at 7, 30, 180, and 365 days. The secondary end points were coronary angiography and coronary artery bypass grafting in those who underwent angiography.

Results  The patients were ages 18 to 64 years with an average age of 44.4 years. A total of 536 197 patients (57.9%) were women. Patients who received testing (224 973) had increased risk at baseline and had greater risk of AMI admission than those who did not receive testing (701 660) (0.35% vs 0.14% at 30 days). Weekday patients (571 988) had similar baseline comorbidities to weekend patients (354 645) but were more likely to receive testing. After risk factor adjustment, testing within 30 days was associated with a significant increase in coronary angiography (36.5 per 1000 patients tested; 95% CI, 21.0-52.0) and revascularization (22.8 per 1000 patients tested; 95% CI, 10.6-35.0) at 1 year but no significant change in AMI admissions (7.8 per 1000 patients tested; 95% CI, −1.4 to 17.0). Testing within 2 days was also associated with a significant increase in coronary revascularization but no difference in AMI admissions.

Conclusions and Relevance  Cardiac testing in patients with chest pain was associated with increased downstream testing and treatment without a reduction in AMI admissions, suggesting that routine testing may not be warranted. Further research into whether specific high-risk subgroups benefit from testing is needed.

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