Major adverse cardiac events after emergency department evaluation of chest pain patients with advanced testing: Systematic review and meta‐analysis

Abstract

Objectives Our primary objective was to describe the risk of major adverse cardiac events (MACE) at 1, 6, and 12 months after a negative coronary computed tomography angiogram (cCTA), electrocardiogram (ECG) stress test, stress echocardiography, and myocardial perfusion scintigraphy (MPS) in low‐ to intermediate‐risk patients. Methods Initially, 952 articles were identified for screening, 81 met criteria for full‐text review, and once risk of bias was assessed, 33 articles were included in this meta‐analysis. We utilized a random‐effects model to assess pooled MACE event proportion for patients undergoing evaluation of acute coronary syndrome (ACS) when risk stratified to a low‐ to intermediate‐risk category after undergoing standard testing. Heterogeneity analysis was performed using Cochrane's Q‐test and I2 statistic. Results Twenty‐one studies evaluated follow‐up at 1 month with cCTA having a 0.09% (95% confidence interval [CI] = 0.03% to 0.26%) pooled MACE compared to 0.23% (95% CI = 0.01% to 5.8%) of the exercise stress testing (p = 1). MPS and cCTA had an overall event rate of 0.15% (95% CI = 0.06% to 0.41%) at 6 months (I2 = 0%). At 12 months, a subgroup analysis found a pooled cCTA MACE of 0.16% (95% CI = 0.04% to 0.65%) compared to 1.68% (95% CI = 0.01% to 2.6%) for stress echocardiography with low within‐group heterogeneity (I2 = 0%). Subgroup analysis of cCTA with no disease versus nonobstructive disease (<50% stenosis) did not find statistical difference in the MACE at both 1 month (0.17% [95% CI = 0.04% to 0.67%] vs. 0.06% [95% CI = 0.01% to 0.34%]) and 12 months (0.44% [95% CI = 0.09% to 2.2% vs. 0.54% [95% CI = 0.19% to 1.5%]). Conclusions Patients presenting with chest pain who have a coronary CTA showing < 50% stenosis, negative ECG stress test, stress echocardiography, or stress myocardial perfusion scan in the past 12 months can be discharged without any further risk stratification if their ECG and troponin are reassuring given low MACE.

Cardiac Biomarkers in 2022 – a Vital Tool for Emergency Care

“…A meta-analysis published by Mehta et al including 21 studies showed that patients with chest pain, negative stress test, and CCTA showing no significant stenosis (no obstruction >50% in any coronary artery) may be discharged safely if their Tn values are not elevated, given the low risk of MACE in this population. 26 Another interesting imaging approach results from the association between cTn sampling and CMR in cases with unclear diagnosis. For instance, the role of a combined approach including troponin and CMR for elucidating MI-NOCA etiology has been tested in another recently published study, which demonstrated that CMR performed <14 days from presentation may elucidate the diagnosis of MINOCA, especially when peak troponin is >211 ng/L (94% diagnostic yield compared with 53% when peak troponin was <211 ng/L).…”