Limited utility of exercise stress testing in the evaluation of suspected acute coronary syndrome in patients aged less than 40 years with intermediate risk features.
OBJECTIVE
National guidelines for management of intermediate risk patients with suspected acute coronary syndrome, in whom AMI has been excluded, advocate provocative testing to final risk stratify these patients into low risk (negative testing) or high risk (positive testing suggestive of unstable angina). Adults less than 40 years have a low pretest probability of acute coronary syndrome. The utility of exercise stress testing in young adults with chest pain suspected of acute coronary syndrome who have National Heart Foundation intermediate risk features was evaluated.


METHODS
A retrospective analysis of exercise stress testing performed on patients less than 40 years was evaluated. Patients were enrolled on a chest pain pathway and had negative serial ECGs and cardiac biomarkers before exercise stress testing to rule-out acute coronary syndrome. Chart review was completed on patients with positive stress tests.


RESULTS
The 3987 patients with suspected intermediate risk acute coronary syndrome underwent exercise stress testing. One thousand and twenty-seven (25.8%) were aged less than 40 years (age 33.3 ± 4.8 years). Four of these 1027 patients had a positive exercise stress test (0.4% incidence of positive exercise stress testing). Of those, three patients had subsequent non-invasive functional testing that yielded a negative result. One patient declined further investigations. Assuming this was a true positive exercise stress test, the incidence of true positive exercise stress testing would have been 0.097% (95% confidence interval: 0.079-0.115%) (one of 1027 patients).


CONCLUSIONS
Routine exercise stress testing has limited value in the risk stratification of adults less than 40 years with suspected intermediate risk of acute coronary syndrome.
Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; School of Public Health, Queensland University of Technology, Brisbane, Queensland, Australia.
Adam C
AC
Scott
Jennifer
J
Bilesky
Arvin
A
Lamanna
Louise
L
Cullen
Anthony F T
AF
Brown
Charles
C
Denaro
William
W
Parsonage
D054058:Acute Coronary Syndrome / Q000175:diagnosis*; D000328:Adult; D002637:Chest Pain / Q000175:diagnosis; D004636:Emergency Service, Hospital; D005080:Exercise Test / Q000379:methods / Q000592:standards*; D005189:False Positive Reactions; D005260:Female; D006801:Humans; D008297:Male; D011793:Queensland; D012189:Retrospective Studies; D018570:Risk Assessment; D055815:Young Adult
acute coronary syndrome; chest pain; emergency department; exercise stress test; major adverse cardiac event