title: Stress myocardial perfusion imaging for the evaluation and triage of chest pain in the emergency department: a randomized controlled trial.
abstract: BACKGROUND
  Patients with acute coronary syndrome (ACS) often present atypically. In a randomized controlled trial, we studied whether adding stress myocardial perfusion imaging (SMPI) to an evaluation strategy for emergency department (ED) patients presenting with chest pain more effectively identifies patients with ACS.
  
  
  METHODS
  Participants were randomized to standard ED chest pain protocol (clinical assessment) or standard protocol supplemented with SMPI results. During 6 hours of electrocardiogram (ECG) monitoring and serial cardiac markers (creatine kinase-MB isoenzyme, troponin), participants developing ST segment changes or elevated cardiac markers were admitted. Those with a negative observation period underwent SMPI (N = 1,004) or clinical assessment (N = 504) based on randomization, and admitted if their SMPI scan was abnormal or senior clinicians found a high or intermediate risk for ACS.
  
  
  RESULTS
  SMPI participants had a significantly lower admission rate than clinical assessment participants (10.16% vs 18.45%), with no significant between-group differences in risk of cardiac events (CEs) after 30 days (0.40% vs 0.79%) or 1 year (0.70% vs 0.99%).
  
  
  CONCLUSIONS
  When added to a standard triage strategy incorporating clinical evaluation, serial ECGs, and cardiac markers, SMPI improved clinical decision making for chest pain patients, significantly reducing the need for hospitalization without an increase in adverse CE rates at 30 days or 1 year.
authors.affiliation: Department of Emergency Medicine, Singapore General Hospital, Outram Road, Singapore, 169608, Singapore, gaelsh@sgh.com.sg.
authors.forename: Swee Han
authors.initials: SH
authors.lastname: Lim
authors.forename: Venkataraman
authors.initials: V
authors.lastname: Anantharaman
authors.forename: Felix
authors.initials: F
authors.lastname: Sundram
authors.forename: Edwin Shih-Yen
authors.initials: ES
authors.lastname: Chan
authors.forename: Ee Sin
authors.initials: ES
authors.lastname: Ang
authors.forename: Sui Lan
authors.initials: SL
authors.lastname: Yo
authors.forename: Edward
authors.initials: E
authors.lastname: Jacob
authors.forename: Anthony
authors.initials: A
authors.lastname: Goh
authors.forename: Say Beng
authors.initials: SB
authors.lastname: Tan
authors.forename: Terrance
authors.initials: T
authors.lastname: Chua
mesh_terms: D000328:Adult; D000368:Aged; D002637:Chest Pain / Q000000981:diagnostic imaging*; D017023:Coronary Angiography; D004562:Electrocardiography; D004636:Emergency Service, Hospital; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D055414:Myocardial Perfusion Imaging; D014218:Triage
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