Yield of Routine Provocative Cardiac Testing Among Patients in an Emergency Department–Based Chest Pain Unit

Hermann, Luke; Newman, David H.; Pleasant, W. Andrew; Rojanasarntikul, Dhanadol; Lakoff, Daniel; Goldberg, Scott A; Duvall, W. Lane; Henzlova, Milena J.

doi:10.1001/jamainternmed.2013.850

Cited by 93 publications

(51 citation statements)

References 24 publications

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“…Earlier studies of ED patients evaluated for chest pain found myocardial infarction rates around 10%, 12 although this may have decreased significantly over the past decade. 11 We do not have myocardial infarction data available for the study ED, but in a previous study of patients undergoing a chest pain protocol in our ED, 11.7% had positive provocative tests, 13 generally consistent with results from studies in other EDs. [14][15][16] Finally, since our survey was anonymous, we are unable to determine the number of unique physicians surveyed or correlate individual physician characteristics with responses beyond the simple demographic data reported.…”

Section: Limitationssupporting

confidence: 71%

The Association Between Medicolegal and Professional Concerns and Chest Pain Admission Rates

et al. 2015

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Objectives: For patients in whom acute coronary syndrome (ACS) is a concern, disposition decisions are complex and multifactorial and have traditionally been a source of considerable variation. An important factor in disposition decisions for these patients may be physician-perceived medicolegal risk and related professional concerns. The study aim was to determine, at the point of care, how much less frequently physicians report that they would admit possible ACS patients if there was either zero or a defined medicolegal risk.Methods: This was a point-of-care emergency physician survey. Research assistants approached physicians at or immediately following the moment of disposition decisions for patients who were being admitted for ACS. The primary outcome measures were the proportion of physicians reporting that patients would not have been admitted if medicolegal issues were of no concern and the proportion of physicians reporting that patients would not have been admitted if there was an "acceptable miss rate" of 1% to 2% for ACS patients.Results: During the 3-month study period, 576 patients were admitted to an inpatient unit or to the ED observation protocol. Physicians were approached in 271 cases, and 259 surveys were completed. When presented with hypothetical zero medicolegal risk, physicians answered that they would not have admitted the patients in 30% of cases. With a hypothetical 1% to 2% acceptable miss rate, physicians indicated that they would not have admitted the patients in 29% of the cases.Conclusions: ED medicolegal and professional concerns may substantially increase admissions for possible ACS. An acceptable miss rate or a zero medicolegal risk environment could potentially lead to a major reduction in admissions that physicians feel to be clinically unnecessary.ACADEMIC EMERGENCY MEDICINE 2015;22:883-886 © 2015 by the Society for Academic Emergency Medicine A cute coronary syndrome (ACS) is a common concern in emergency department (ED) settings and a common reason for extended evaluation using accelerated diagnostic protocols in observation units or inpatient hospital settings. For patients in whom ACS is a concern, disposition decisions are complex and multifactorial and have traditionally been a source of considerable variation.1,2 An important factor in disposition decisions for these patients may be physician-perceived medicolegal risk and related professional concerns. [3][4][5] Previous work has been done examining the concept of a test threshold, or "acceptable miss rate," for ACS. [6][7][8] However, such thresholds have not been routinely integrated into disposition decision-making and their possible effect on physician decision-making has, to our knowledge, not been previously reported.We aimed to determine, at the point of care, how often perceived medicolegal concerns affect physician

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Section: Limitationssupporting

confidence: 71%

The Association Between Medicolegal and Professional Concerns and Chest Pain Admission Rates

et al. 2015

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“…11,12 Our study demonstrated a similar yield with 9.0% of patients having ≥5% ischemic myocardium. Unlike these previous studies, a greater percentage of our patients with evidence of ischemia subsequently had invasive coronary angiography.…”

Section: Previous Studies Of Routine Provocative Testing To Risk Strasupporting

confidence: 70%

Myocardial Perfusion Imaging in Emergency Department Patients With Negative Cardiac Biomarkers

Cremer

Khalaf

Agarwal

et al. 2014

Circ: Cardiovascular Imaging

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Background-In patients with possible acute coronary syndromes, guidelines recommend routine provocative testing after negative cardiac biomarkers. We hypothesized that myocardial perfusion imaging would be low yield with limited shortterm value and that early revascularization would not affect mortality. Methods and Results-We identified consecutive patients referred from our emergency department between October 2004 and September 2011 who had myocardial perfusion imaging after negative troponin T tests and nondiagnostic ECGs.We assessed the incidence of abnormal myocardial perfusion imaging, coronary angiography, revascularization, and mortality. In a cohort of 5354 patients (58.7% female, age 59±13, 78.6% thrombolysis in myocardial infarction [TIMI] ≤2), 9% had >5% and 3.6% had >10% ischemic myocardium. Among patients with TIMI scores ≤2, 6.1% had >5% ischemic myocardium compared with 19.6% of patients with TIMI scores ≥3 (P<0.001). At 30 days, 7 patients were deceased, 187 had revascularization, and 6 had revascularization for an acute myocardial infarction. Over 3.4±1.9 years of follow-up, 347 patients died. In propensity-matched groups of patients with ischemia, there was no association between early revascularization and mortality (hazard ratio, 1.00; 95% confidence interval, 0.49-2.07). Conclusions-Routine provocative testing to detect ischemia before emergency department discharge is low yield in patients with negative troponins and TIMI scores ≤2 and modest yield in patients with TIMI scores ≥3. In all patients, 30 days events are rare. Finally, in patients with ischemia, we are unable to demonstrate a mortality benefit with early revascularization. (Circ Cardiovasc Imaging. 2014;7:912-919.)

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“…7,[10][11][12][13] As one example, a recent large retrospective analysis by Sandhu et al looked at an insurance claims database of over 900,000 ED chest pain patients with initial negative workups. The results showed no significant reduction in subsequent admissions for acute MIs in patients who underwent noninvasive cardiac testing for further risk stratification.…”

mentioning

confidence: 99%

Provocative testing for low-risk chest pain patients, must we continue?

Booth

Thomas

2019

Journal of Nuclear Cardiology

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Yield of Routine Provocative Cardiac Testing Among Patients in an Emergency Department–Based Chest Pain Unit

Cited by 93 publications

References 24 publications

The Association Between Medicolegal and Professional Concerns and Chest Pain Admission Rates

The Association Between Medicolegal and Professional Concerns and Chest Pain Admission Rates

Myocardial Perfusion Imaging in Emergency Department Patients With Negative Cardiac Biomarkers

Provocative testing for low-risk chest pain patients, must we continue?

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