Emergency department evaluation of chest pain using exercise stress echocardiography
M Buchsbaum1, E Marshall, B Levine
1Department of Emergency Medicine, Christiana Care Health Services, Newark, DE, USA.
Insights
Exercise stress echocardiography (ESE) safely evaluates low-risk emergency department chest pain patients. A normal ESE result indicates minimal risk, supporting patient discharge.
Area of Science:
- Cardiology
- Diagnostic Imaging
- Emergency Medicine
Background:
- Chest pain in the emergency department (ED) presents a diagnostic challenge, particularly in low-risk patients.
- A small percentage of low-risk patients may experience acute myocardial infarction (MI) or sudden death.
- Differentiating true cardiac events from non-cardiac causes is crucial for appropriate patient management.
Purpose of the Study:
- To assess the utility of exercise stress echocardiography (ESE) in evaluating low-risk patients with chest pain in the ED.
- To determine if ESE can support the safe discharge of selected low-risk chest pain patients.
- To establish the diagnostic accuracy of ESE in this patient population.
Main Methods:
- Prospective observational cohort study of 145 patients aged >=30 presenting to the ED with chest pain, normal initial cardiac biomarkers, and ECG.
- Patients underwent exercise stress echocardiography (ESE) within 6 hours of presentation.
- Abnormal ESE was defined by resting or exercise-induced regional wall motion abnormalities; outcomes and cardiac events were tracked for 6 months.
Main Results:
- Seven out of 145 patients (5%) had abnormal ESE results.
- Three patients with abnormal ESE were diagnosed with coronary artery disease (CAD) after cardiac catheterization.
- Of 138 patients with normal ESE, only one experienced a non-Q-wave MI at 6 months, yielding a negative predictive value of 99.3%.
Conclusions:
- Exercise stress echocardiography (ESE) is a valuable tool for evaluating low-risk chest pain patients in the emergency department.
- A normal ESE result in these patients allows for safe discharge with a very low risk of subsequent cardiac events.
- ESE aids in risk stratification and facilitates efficient patient disposition from the ED.
Objective:
Patients with a low risk of coronary artery disease (CAD) presenting to the emergency department (ED) with chest pain pose a diagnostic dilemma because a small percentage will suffer an acute myocardial infarction (MI) and sudden death. The authors conducted this study to determine whether exercise stress echocardiography (ESE) could be used to further support the safe discharge of these low-risk patients.
Methods:
A convenience sample of patients > or =30 years of age without a prior cardiac history who presented to an academic community hospital with chest pain, normal initial creatine kinase, and electrocardiography without ischemic changes underwent ESE within 6 +/- 1.7 hours (mean +/- SD). Abnormal ESE was defined as regional wall motion abnormality at rest or after exercise. The ED disposition and three- and six-month follow-up for cardiac events were recorded. This was a prospective observational cohort study.
Results:
Of a total of 149 eligible patients, 145 completed the study. The mean age (+/-SD) was 47 +/- 9 years; 56% were male. No adverse events were noted during ESE. Seven patients (5%) had abnormal ESE (2 with rest wall motion abnormalities and 5 with exercise-induced wall motion abnormalities). Five of the seven underwent cardiac catheterization; three had CAD. All patients received telephone follow-up at three months and six months. Of the 138 patients with a normal ESE, all were free of cardiac events at three months. One patient had a non-Q-wave MI at six months (negative predictive value = 99.3%, 95% CI = 97.8% to 100%).
Conclusions:
Exercise stress echocardiography can be used to evaluate low-risk chest pain patients in the ED. Patients with a normal ESE may be considered for discharge with minimal risk of sequelae.
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