Does clinical evaluation plus noninvasive cardiac testing improve outcomes?

November 15th, 2017
Bottom Line: Ordering coronary computed tomographic angiography (CCTA) or stress testing for patients with chest pain in the emergency department appeared to prolong their stay and increase use of hospital resources without benefit if the patients' history and physical exam, ectrocardiogram (ECG) and blood testing were already normal.

Why The Research Is Interesting: CCTA is a noninvasive imaging test that can detect coronary artery disease, the underlying cause of acute coronary syndrome (ACS or "heart attack"). A previous trial showed that adding CCTA to evaluation of patients with symptoms suggestive of ACS decreased the time people needed to wait to be diagnosed in the emergency room. This study uses data from the same trial to compare what happened to patients who did and did not undergo noninvasive testing (CCTA or stress testing).

Who: 1,000 patients who came to emergency departments with chest pain at nine hospitals in the United States

What (Study Measures): Noninvasive cardiac testing with CCTA or stress testing (exposure); length of stay in the emergency department, costs, other testing later, cumulative radiation exposure from cardiac testing, major adverse cardiac events and repeated emergency department visits over a 28-day period (outcomes).

How and When (Study Design): The study was a secondary analysis of data from a randomized clinical trial.

Authors: David L. Brown, M.D., Washington University School of Medicine, St. Louis, and coauthors

Results: Patients who underwent clinical evaluation plus noninvasive testing spent more time at the hospital, had more tests, were exposed to more radiation in those tests and incurred greater costs without an apparent improvement in clinical outcomes.

There also was no difference in the rate of return emergency department visits, no missed cases of ACS in either group and no difference in major adverse cardiac events during the 28-day follow-up. More cases of ACS were diagnosed in patients who underwent noninvasive testing.

Study Limitations: The two groups analyzed were not randomized so differences between the groups could exist that weren't measured. The study also had a short follow-up of 28 days.

More information:
Samuel W. Reinhardt et al. Noninvasive Cardiac Testing vs Clinical Evaluation Alone in Acute Chest Pain, JAMA Internal Medicine (2017). DOI: 10.1001/jamainternmed.2017.7360 , http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/10.1001/jamainternmed.2017.7360

Provided by The JAMA Network Journals

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