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    1 Comment for this article
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    Where now for the evaluation of chest pain in the emergency department?
    Joseph A. Ladapo, MD, PhD | New York University School of Medicine
    Foy et al examine a frequently encountered and important clinical scenario in their study: the low-risk patient presenting to the emergency department with chest pain.(1) After ruling out acutely life-threatening etiologies and being unable to identify other acute, non-cardiac diagnoses, the clinician must decide whether or not to perform additional cardiac testing. While many centers exercise a low threshold for determining which patients should be referred for additional cardiac stress testing—indeed, the heuristic may even be “built into” some residency training programs—Foy et al cast doubt on the clinical wisdom of this pathway. Despite the limitations of insurance claims data evaluations of patient management decisions—the principal one being dearth of clinical information about patient symptoms—the extremely low rate of adverse cardiac events during follow-up among both patients who did and did not undergo cardiac stress testing are compelling—and supported by some(2)—but not all(3)—studies. Their study is also an elegant demonstration of the diagnostic-therapeutic cascade that often accompanies an initial diagnostic test, sometimes exposing patients to risk with little clinical reward at the end of their journeys.(4) Considering the frequency of chest pain presentations to emergency departments and the high prevalence of cardiac stress testing—and increasingly, coronary computed tomography angiography—in the United States,(5) a clinical trial that robustly compared usual care to “no additional cardiac testing” in low-risk patients could yield a favorable return on investment on a national level. However, because studies using more clinically-oriented data have sometimes reported modestly higher rates of acute coronary syndrome during follow-up,(3) a key first step will be identifying characteristics that robustly predict which patients are at an acceptably low risk for adverse events.References1. Foy AJ, Liu G, Davidson WR, Jr., Sciamanna C, Leslie DL. Comparative Effectiveness of Diagnostic Testing Strategies in Emergency Department Patients With Chest Pain: An Analysis of Downstream Testing, Interventions, and Outcomes. JAMA Intern Med 2015;175:428-36.2. Meyer MC, Mooney RP, Sekera AK. A critical pathway for patients with acute chest pain and low risk for short-term adverse cardiac events: role of outpatient stress testing. Ann Emerg Med 2006;47:427-35.3. Goldstein JA, Chinnaiyan KM, Abidov A, et al. The CT-STAT (Coronary Computed Tomographic Angiography for Systematic Triage of Acute Chest Pain Patients to Treatment) trial. J Am Coll Cardiol 2011;58:1414-22.4. Lucas FL, Siewers AE, Malenka DJ, Wennberg DE. Diagnostic-therapeutic cascade revisited: coronary angiography, coronary artery bypass graft surgery, and percutaneous coronary intervention in the modern era. Circulation 2008;118:2797-802.5. Ladapo JA, Blecker S, Douglas PS. Physician Decision Making and Trends in the Use of Cardiac Stress Testing in the United States: An Analysis of Repeated Cross-sectional Data. Ann Intern Med 2014;161:482-90.
    CONFLICT OF INTEREST: None Reported
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    Original Investigation
    March 2015

    Comparative Effectiveness of Diagnostic Testing Strategies in Emergency Department Patients With Chest Pain: An Analysis of Downstream Testing, Interventions, and Outcomes

    Author Affiliations
    • 1Division of Cardiology, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
    • 2Department of Public Health Sciences, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
    • 3Division of Internal Medicine, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
    JAMA Intern Med. 2015;175(3):428-436. doi:10.1001/jamainternmed.2014.7657
    Abstract

    Importance  Patients presenting to the emergency department (ED) with chest pain whose evaluation for ischemia demonstrates no abnormalities receive further functional or anatomical studies for coronary artery disease; however, comparative evidence for the various strategies is lacking and multiple testing options exist.

    Objective  To compare chest pain evaluation pathways based on their association with downstream testing, interventions, and outcomes for patients in EDs.

    Design, Setting, and Participants  Retrospective analysis of health insurance claims data for a national sample of privately insured patients from January 1 to December 31, 2011. Individuals with a primary or secondary diagnosis of chest pain in the ED were selected and classified into 1 of 5 testing strategies: no noninvasive testing, exercise electrocardiography, stress echocardiography, myocardial perfusion scintigraphy, or coronary computed tomography angiography.

    Main Outcomes and Measures  The proportion of patients in each group who received a cardiac catheterization, coronary revascularization procedure, or future noninvasive test as well as those who were hospitalized for an acute myocardial infarction (MI) during 7 and 190 days of follow-up.

    Results  In 2011, there were 693 212 ED visits with a primary or secondary diagnosis of chest pain, accounting for 9.2% of all ED encounters. After application of the inclusion and exclusion criteria, 421 774 patients were included in the final analysis; 293 788 individuals did not receive an initial noninvasive test and 127 986 did, representing 1.7% of all ED encounters. Overall, the percentage of patients hospitalized with an MI was very low during both 7 and 190 days of follow-up (0.11% and 0.33%, respectively). Patients who did not undergo initial noninvasive testing were no more likely to experience an MI than were those who did receive testing. Compared with no testing, exercise electrocardiography, myocardial perfusion scintigraphy, and coronary computed tomography angiography were associated with significantly higher odds of cardiac catheterization and revascularization procedures without a concomitant improvement in the odds of experiencing an MI.

    Conclusions and Relevance  Patients with chest pain evaluated in the ED who do not have an MI are at very low risk of experiencing an MI during short- and longer-term follow-up in a cohort of privately insured patients. This low risk does not appear to be affected by the initial testing strategy. Deferral of early noninvasive testing appears to be reasonable.

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