title: Value of definitive diagnostic testing in the evaluation of patients presenting to the emergency department with chest pain.
abstract: The optimal diagnostic evaluation of patients presenting to the emergency department (ED) with chest pain but without myocardial infarction or unstable angina is controversial. We performed a prospective, nonrandomized, observational study of 1,195 consecutive patients presenting to the ED with chest pain but who had normal or nondiagnostic electrocardiograms and negative cardiac biomarkers. Patients (mean +/- SD age 61 +/- 15 years; 55% women) were admitted to the hospital and a standard protocol for evaluation and treatment was suggested. The use of stress myocardial perfusion imaging (MPI) or cardiac catheterization during their index hospitalization, and the 3-month incidence of coronary angiography, percutaneous cardiac intervention, coronary artery bypass surgery, re-presentation to our institution's ED for chest pain, myocardial infarction, or death were followed. Five hundred nine of 1,195 patients (43%) underwent provocative stress MPI during their index hospitalization; 37% had perfusion defects (predominantly ischemia). Fifty-six of 1,195 patients (4%) underwent cardiac catheterization without stress MPI for their primary diagnostic evaluation. Six hundred thirty of 1,195 patients (53%) had neither MPI or cardiac catheterization during their index hospitalization. During the 3-month follow-up period, patients with a normal stress perfusion study during their index hospitalization had fewer return visits (4%) compared with patients with abnormal perfusion studies (19%), those who underwent catheterization directly (16%), or patients with no initial diagnostic evaluation (15%) (p <0.001). In addition, patients who had a diagnostic evaluation during their index hospitalization had a lower incidence of either acute myocardial infarction (0.9% vs 2.1%) or death (0.4% vs 3.0%, p <0.001) in the 3-month follow-up period. Accordingly, we strongly advocate provocative stress MPI early after presentation for chest pain in all patients with risk factors for coronary artery disease.
authors.affiliation: Division of Cardiology, Department of Medicine, College of Physicians & Surgeons, Columbia University, 630 West 168th Street, New York, NY 10032, USA.
authors.forename: Abu
authors.initials: A
authors.lastname: Shoyeb
authors.forename: Sabahat
authors.initials: S
authors.lastname: Bokhari
authors.forename: Jennifer
authors.initials: J
authors.lastname: Sullivan
authors.forename: Eileen
authors.initials: E
authors.lastname: Hurley
authors.forename: Bernadette
authors.initials: B
authors.lastname: Miesner
authors.forename: Raffaela
authors.initials: R
authors.lastname: Pia
authors.forename: James
authors.initials: J
authors.lastname: Giglio
authors.forename: Osman R
authors.initials: OR
authors.lastname: Sayan
authors.forename: Lucy
authors.initials: L
authors.lastname: Soto
authors.forename: Simbo
authors.initials: S
authors.lastname: Chiadika
authors.forename: Cristina
authors.initials: C
authors.lastname: LaMarca
authors.forename: LeRoy E
authors.initials: LE
authors.lastname: Rabbani
authors.forename: Steven R
authors.initials: SR
authors.lastname: Bergmann
mesh_terms: D000367:Age Factors; D000368:Aged; D006328:Cardiac Catheterization; D002637:Chest Pain / Q000175:diagnosis* / Q000453:epidemiology / Q000628:therapy; D003324:Coronary Artery Disease / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy; D004562:Electrocardiography; D004636:Emergency Service, Hospital / Q000592:standards; D005080:Exercise Test; D005260:Female; D005500:Follow-Up Studies; D006760:Hospitalization; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D015425:Myocardial Reperfusion; D009518:New York / Q000453:epidemiology; D011446:Prospective Studies; D012307:Risk Factors; D012680:Sensitivity and Specificity; D012737:Sex Factors