Title says it all. And it’s all been said before. David Newman is unsurprisingly involved in this paper and the SMART EM on this is well worth your time.
What they did:
- prospective data on their chest pain unit with some chart review (with good but not fully described methods)
- their routine was a 6 hour rule out then EST if possible or nuclear testing (which we don’t seem to do much of over here)
What they found:
- mainly young patients (50) and mainly female and lots of hypertensives
- about 80% were considered intermediate risk. Which is interesting in itself seeing as so many ended up discharged with negative tests
- of the 4000 with stress tests ,470 had positive tests
- ultimately about 130 got angios and only half of them had obstructive disease
- only 28 got appropriate intervention as defined by cardiology guidelines. Lots of other people got stents but probably shouldn’t have.
Their discussion includes this phrase
While AHA guidelines suggest that provocative testing risk stratifies patients to a potentially near-zero short-term adverse event rate, there is increasing recognition that a negative result on serial bio-marker evaluation (typically a prerequisite for provocative testing) may also achieve this goal, making further risk stratification attempts redundant or inherently difficult.
Hermann, Luke K, David H Newman, W Andrew Pleasant, Dhanadol Rojanasarntikul, Daniel Lakoff, Scott A Goldberg, W Lane Duvall, and Milena J Henzlova. “Yield of Routine Provocative Cardiac Testing Among Patients in an Emergency Department-Based Chest Pain Unit: Yield of Stress Testing in Emergency Department Observation Units..” JAMA Internal Medicine (May 20, 2013): 1–6. PMID 23689690