Cardiovascular Testing and Clinical Outcomes in Emergency Department Patients With Chest Pain

Abstract

Importance: Noninvasive testing and coronary angiography are used to evaluate patients who present to the emergency department (ED) with chest pain, but their effects on outcomes are uncertain.

Objective: To determine whether cardiovascular testing-noninvasive imaging or coronary angiography-is associated with changes in the rates of coronary revascularization or acute myocardial infarction (AMI) admission in patients who present to the ED with chest pain without initial findings of ischemia.

Design, setting, and participants: This retrospective cohort analysis used weekday (Monday-Thursday) vs weekend (Friday-Sunday) presentation as an instrument to adjust for unobserved case-mix variation (selection bias) between 2011 and 2012. National claims data (Truven MarketScan) was used. The data included a total of 926 633 privately insured patients ages 18 to 64 years who presented to the ED with chest pain without initial diagnosis consistent with acute ischemia.

Exposures: Noninvasive testing or coronary angiography within 2 days or 30 days of presentation.

Main outcomes and measures: The primary end points were coronary revascularization (percutaneous coronary intervention or coronary artery bypass graft surgery) and AMI admission at 7, 30, 180, and 365 days. The secondary end points were coronary angiography and coronary artery bypass grafting in those who underwent angiography.

Results: The patients were ages 18 to 64 years with an average age of 44.4 years. A total of 536 197 patients (57.9%) were women. Patients who received testing (224 973) had increased risk at baseline and had greater risk of AMI admission than those who did not receive testing (701 660) (0.35% vs 0.14% at 30 days). Weekday patients (571 988) had similar baseline comorbidities to weekend patients (354 645) but were more likely to receive testing. After risk factor adjustment, testing within 30 days was associated with a significant increase in coronary angiography (36.5 per 1000 patients tested; 95% CI, 21.0-52.0) and revascularization (22.8 per 1000 patients tested; 95% CI, 10.6-35.0) at 1 year but no significant change in AMI admissions (7.8 per 1000 patients tested; 95% CI, -1.4 to 17.0). Testing within 2 days was also associated with a significant increase in coronary revascularization but no difference in AMI admissions.

Conclusions and relevance: Cardiac testing in patients with chest pain was associated with increased downstream testing and treatment without a reduction in AMI admissions, suggesting that routine testing may not be warranted. Further research into whether specific high-risk subgroups benefit from testing is needed.

Figure.. Subgroup Analyses of Effect of Cardiac Testing Per 1000 Patients at 1 Year

Results are presented as the change in outcome associated with performing testing in 1000 patients (standard error) in each subgroup, estimated using the average marginal effect for each subgroup. Presented P values are the difference between the average marginal effects in paired subgroups (ie, women and men) in 1000 bootstrapped samples. Cardiac testing includes either noninvasive test (exercise electrocardiography, stress echocardiography, myocardial perfusion scan, and cardiac computed tomographic angiography) or coronary angiography. Analyses were adjusted for age; sex; comorbid conditions (diabetes, hypertension, hyperlipidemia, chronic kidney disease, cerebrovascular disease, peripheral vascular disease, tobacco use); and history of ischemic heart disease, noninvasive test in the previous year, coronary angiography in the previous year, antiplatelet medication use, and antihyperlipidemic medication use. Revascularization is either coronary artery bypass graft surgery or percutaneous coronary intervention. AMI indicates acute myocardial infarction; ED, emergency department. Error bars indicate standard error.