Risk stratification and role for additional diagnostic testing in patients with acute chest pain and normal
Martijn W Smulders1,2, Sebastiaan C A M Bekkers1,2,3, Yvonne J M van Cauteren1,2,3
1Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands.
Insights
Clinical characteristics effectively identify low-risk patients with normal high-sensitivity cardiac troponin (hs-cTn) levels, reducing unnecessary cardiac testing. This approach enhances diagnostic yield and avoids low-yield tests in low-risk acute chest pain patients.
Area of Science:
- Cardiology
- Emergency Medicine
- Diagnostic Testing
Background:
- High-sensitivity cardiac troponin (hs-cTn) assays accurately rule out acute myocardial infarction (AMI).
- Despite accurate hs-cTn assays, additional non-invasive testing is common for acute chest pain patients.
- Risk stratification using clinical characteristics may optimize the use of further diagnostic tests.
Purpose of the Study:
- To evaluate if clinical characteristics can stratify risk in patients with acute chest pain and normal hs-cTn levels.
- To determine if clinical assessment can guide the need for additional non-invasive testing.
- To analyze the diagnostic yield of additional tests based on risk stratification.
Main Methods:
- Prospective observational study of 918 patients with acute chest pain and normal hs-cTnT.
- Assessment of major adverse cardiac events (MACE) and non-invasive test results over one-year follow-up.
- Classification of patients into low and high risk based on clinical characteristics.
Main Results:
- MACE occurred in 6.1% of patients, primarily revascularizations.
- Abnormal stress tests, suspicious history, family history, and higher hs-cTnT levels predicted MACE.
- Absence of abnormal stress test and suspicious history identified 86% of patients at very low risk (0.4% 30-day MACE).
- Most additional tests (83%) were performed in low-risk patients with low diagnostic yield (<10% abnormal).
- Higher risk patients showed higher diagnostic yield (40% abnormal tests, 70% PPV for MACE).
Conclusions:
- Clinical characteristics effectively identify low-risk patients with acute chest pain and normal hs-cTnT.
- Current emergency department strategies lead to frequent, low-yield testing in low-risk individuals.
- Risk stratification using clinical features can improve the efficiency and diagnostic yield of further testing.
Background:
Normal high sensitivity cardiac troponin (hs-cTn) assays rule out acute myocardial infarction (AMI) with great accuracy, but additional non-invasive testing is frequently ordered. This observational study evaluates whether clinical characteristics can contribute to risk stratification and could guide referral for additional testing.
Methods:
918 serial patients with acute chest pain and normal hs-cTnT levels were prospectively included. Major adverse cardiac events (MACE) and non-invasive test results were assessed during one-year follow-up. Patients were classified as low and high risk based on clinical characteristics.
Results:
MACE occurred in 6.1% of patients and mainly comprised revascularizations (86%). A recent abnormal stress test, suspicious history, a positive family history and higher baseline hs-cTnT levels were independent predictors of MACE with odds ratios of 16.00 (95%CI:6.25-40.96), 16.43 (6.36-42.45), 2.33 (1.22-4.42) and 1.10 (1.01-1.21), respectively. Absence of both recent abnormal stress test and suspicious history identified 86% of patients. These patients were at very low risk for MACE (0.4% in 30-days and 2.3% in one-year). Despite this, the majority (287/345 = 83%) of additional tests were performed in low risk patients, with <10% abnormal test findings. The diagnostic yield was significantly higher in the remaining higher risk patients, 40% abnormal test findings and a positive predictive value of 70% for MACE. Similar results were observed in patients without known coronary artery disease.
Conclusions:
Clinical characteristics can be used to identify low risk patients with acute chest pain and normal hs-cTnT levels. Current strategies in the emergency department result in numerous additional tests, which are mostly ordered in patients at very low risk and have a low diagnostic yield.
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