The incremental value of stress testing in patients with acute chest pain beyond serial cardiac troponin testing
Sally Aldous1, A Mark Richards2, Louise Cullen3
1Cardiology Department, Christchurch Hospital, Christchurch, New Zealand.
Insights
Stress testing in acute chest pain patients with normal troponin identified 4.5% needing revascularization. This helps clinicians decide if identifying these patients prevents future adverse cardiac events.
Area of Science:
- Cardiology
- Diagnostic Imaging
- Acute Coronary Syndromes
Background:
- Risk stratification for acute coronary syndrome (ACS) is challenging in patients presenting with acute chest pain and normal cardiac troponin (cTn) levels.
- Accurate identification of ACS is crucial for timely intervention and prevention of adverse cardiac events.
Purpose of the Study:
- To assess the incremental value of stress testing in patients with acute chest pain and normal cTn.
- To determine if stress testing aids in identifying patients who would benefit from angiography and revascularization.
Main Methods:
- A single-centre observational study included patients with acute chest pain and negative serial cTn tests.
- Stress testing, including exercise tolerance testing and dobutamine stress echocardiography, was performed.
- Primary outcomes included revascularization during index admission and 1-year follow-up for cardiac death and myocardial infarction.
Main Results:
- Of 749 patients, 73.2% had negative stress tests, 22.6% non-diagnostic, and 4.3% positive.
- Patients with positive stress tests were significantly more likely to undergo revascularization (59.4%) compared to non-diagnostic (8.9%) and negative (0.4%) tests (p<0.001).
- Adverse events (cardiovascular death/myocardial infarction) were low and similar across all stress test outcome groups.
Conclusions:
- Stress testing identified an additional 4.5% of patients who underwent revascularization during their index admission.
- The decision to use stress testing in this population depends on the perceived clinical value of identifying this subgroup for potential preventative revascularization.
- Further research may be needed to clarify the long-term benefits of revascularization in patients with negative cTn levels.
Objective:
In patients with acute chest pain and normal range cardiac troponin (cTn), accurate risk stratification for acute coronary syndrome is challenging. This study assesses the incremental value of stress testing to identify patients for angiography with a view to revascularisation.
Methods:
A single-centre observational study recruited patients with acute chest pain in whom serial cTn tests were negative and stress testing (exercise tolerance testing/dobutamine stress echocardiography) was performed. Stress tests were reported as negative, non-diagnostic or positive. The primary outcomes were revascularisation on index admission, or cardiac death and myocardial infarction over 1 year follow-up.
Results:
Of 749 patients recruited, 709 underwent exercise tolerance testing and 40 dobutamine stress echo of which 548 (73.2%) were negative, 169 (22.6%) were non-diagnostic and 32 (4.3%) were positive. Patients with positive tests (n=19 (59.4%)) were more likely to undergo index admission revascularisation than patients with non-diagnostic (n=15 (8.9%)) (p<0.001) tests who in turn were more likely undergo index admission revascularisation than those with negative tests (n=2 (0.4%)) (p<0.001). The risks of adverse events including cardiovascular death/acute myocardial infarction were low and were similar across stress test outcomes.
Conclusions:
The incremental value of stress testing was the identification of an additional 34 (4.5% (95% CI 3.0% to 6.0%)) patients who underwent index admission revascularisation with a view to preventing future adverse events. Uncertainty in whether revascularisation prevents adverse events in patients with negative cTn means the choice to undertake stress testing depends on whether clinicians perceive value in identifying 4.5% of these patients for revascularisation.
Clinical Trial Registrations:
ACTRN1260900028327, ACTRN12611001069943.
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