Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Multicenter Study
. 2020 Dec 1;180(12):1621-1629.
doi: 10.1001/jamainternmed.2020.4325.

Early Noninvasive Cardiac Testing After Emergency Department Evaluation for Suspected Acute Coronary Syndrome

Aniket A Kawatkar  1 , Adam L Sharp  1 , Aileen S Baecker  1 , Shaw Natsui  2 , Rita F Redberg  3   4 , Ming-Sum Lee  5 , Maros Ferencik  6 , Yi-Lin Wu  1 , Ernest Shen  1 , Chengyi Zheng  1 , Visanee V Musigdilok  1 , Michael K Gould  1 , Steve Goodacre  7 , Praveen Thokala  7 , Benjamin C Sun  8
Affiliations
Multicenter Study

Early Noninvasive Cardiac Testing After Emergency Department Evaluation for Suspected Acute Coronary Syndrome

Aniket A Kawatkar et al. JAMA Intern Med. .

Abstract

Importance: Professional guidelines recommend noninvasive cardiac testing (NIT) within 72 hours of an emergency department (ED) evaluation for suspected acute coronary syndrome. However, there is inexact evidence that this strategy reduces the risk of future death or acute myocardial infarction (MI).

Objective: To evaluate the effectiveness of early NIT in reducing the risk of death or acute MI within 30 days.

Design, setting, and participants: This retrospective, multicenter cohort study within the Kaiser Permanente Southern California integrated health care delivery system compared the effectiveness of early noninvasive cardiac testing vs no testing in patients with chest pain and in whom acute MI was ruled out who presented to an ED from January 2015 to December 2017. Patients were followed up for up to 30 days after emergency department discharge.

Exposures: Noninvasive cardiac testing performed within 3 days of an ED evaluation for suspected acute coronary syndrome.

Main outcomes and measures: The primary outcome was composite risk of death or acute MI, within 30 days of an ED discharge.

Results: A total of 79 040 patients were evaluated in this study, of whom 57.7% were female. The mean (SD) age of the cohort was 57 (16) years, and 16 164 patients (21%) had completed early NIT. The absolute risk of death or MI within 30 days was low (<1%). Early NIT had the minor benefit of reducing the absolute composite risk of death or MI (0.4% [95% CI, -0.6% to -0.3%]), and, separately, of death (0.2% [95% CI, -0.2% to -0.1%]), MI (-0.3% [95% CI, -0.5% to -0.1%]), and major adverse cardiac event (-0.5% [95% CI, -0.7% to -0.3%]). The number needed to treat was 250 to avoid 1 death or MI, 500 to avoid 1 death, 333 to avoid 1 MI, and 200 to avoid 1 major adverse cardiovascular event within 30 days. Subgroup analysis revealed a number needed to treat of 14 to avoid 1 death or MI in the subset of patients with elevated troponin.

Conclusions and relevance: Early NIT was associated with a small decrease in the risk of death or MI in patients admitted to the ED with suspected acute coronary syndrome, but this clinical strategy may not be optimal for most patients given the large number needed to treat.

PubMed Disclaimer

Conflict of interest statement

Conflict of Interest Disclosures: Dr Kawatkar reported grants from the National Institutes of Health and the National Heart, Lung, and Blood Institute during the conduct of the study. Dr Sharp reported grants from National Institutes of Health and the National Heart, Lung, and Blood Institute during the conduct of the study. Dr Baecker reported grants from National Institutes of Health during the conduct of the study. Dr Ferencik reported grants from the National Institutes of Health during the conduct of the study. Dr Wu reported grants from the National Institutes of Health during the conduct of the study. Dr Zheng reported grants from National Institutes of Health during the conduct of the study. Dr Gould reported grants from the National Institutes of Health and the National Heart, Lung, and Blood Institute during the conduct of the study. Dr Goodacre reported grants from National Institute for Health during the conduct of the study. Dr Thokala reported grants from the University of Pennsylvania during the conduct of the study. Dr Sun reported grants from the National Institutes of Health and the National Heart, Lung, and Blood Institute during the conduct of the study, has served as expert witness for Winston & Strawn LLP and Fish & Richardson, was a consultant for Medtronic, and has received research support from Roche. Dr Goodacre has undertaken consultancy on behalf of the University of Sheffield for Creavo Industries. Dr Thokala has undertaken private consultancy for Roche. No other disclosures were reported.

Figures

Figure.
Figure.. Flowchart of Patients Presenting With Chest Pain to an Emergency Department (ED) and Patients Included in the Analysis
KPSC indicates Kaiser Permanente Southern California; MI, myocardial infarction; NIT, noninvasive cardiac testing.
See this image and copyright information in PMC

Comment in

Similar articles

See all similar articles

Cited by

See all "Cited by" articles

References

    1. Vedanthan R, Seligman B, Fuster V. Global perspective on acute coronary syndrome: a burden on the young and poor. Circ Res. 2014;114(12):1959-1975. doi:10.1161/CIRCRESAHA.114.302782 - DOI - PMC - PubMed
    1. Foy AJ, Liu G, Davidson WR Jr, Sciamanna C, Leslie DL. Comparative effectiveness of diagnostic testing strategies in emergency department patients with chest pain: an analysis of downstream testing, interventions, and outcomes. JAMA Intern Med. 2015;175(3):428-436. doi:10.1001/jamainternmed.2014.7657 - DOI - PMC - PubMed
    1. US Centers for Disease Control . National Hospital Ambulatory Medical Care Survey: 2010 emergency department summary tables. 2010. Accessed September 8, 2020. https://www.cdc.gov/nchs/data/ahcd/nhamcs_emergency/2010_ed_web_tables.pdf
    1. US Centers for Disease Control/National Center for Health Statistics. Emergency department visits for chest pain and abdominal pain: United States, 1999-2008. 2010. Accessed September 16, 2014. https://www.cdc.gov/nchs/data/databriefs/db43.pdf
    1. Sharp AL, Baecker AS, Shen E, et al. . Effect of a HEART care pathway on chest pain management within an integrated health system. Ann Emerg Med. 2019;74(2):171-180. doi:10.1016/j.annemergmed.2019.01.007 - DOI - PMC - PubMed

Publication types