Appropriate use of multimodality stress testing for chest pain in new patient referrals to cardiologists

In response to the growing use of imaging-based cardiac stress tests in the evaluation of stable ischemic heart disease, professional societies have developed appropriate use criteria (AUC). AUC will soon be linked to reimbursement of advanced diagnostic imaging for Medicare beneficiaries via Clinical Decision Support Mechanisms (CDSMs). We sought to characterize the frequency and type of stress test utilization for chest pain referrals evaluated by cardiologists and determine appropriateness.

We conducted a retrospective review of new patient referrals seen by general cardiologists at an academic medical center between 2016 and 2017 for a diagnosis of chest pain or angina. Type of stress test ordered, if any, and its appropriateness (Appropriate, May be appropriate, and Rarely appropriate) were ascertained based on the 2013 multimodality AUC guideline document.

There were 535 total outpatients. After applying exclusion criteria, there were 349 patients in the sample; the average age was 52 ± 15 years and 53% were female. Most chest pain was nonanginal (65%). Pretest probability of CAD was most commonly intermediate (54%). A total of 183 patients (52%) were referred for stress testing. The majority of stress tests were considered appropriate (82%) by AUC.

Most patients referred to cardiologists for evaluation of chest pain or angina had nonanginal chest pain and an intermediate pretest probability of CAD. Stress testing was ordered in about half of these patients and the majority were considered appropriate by AUC. These findings suggest that indiscriminate use of CDSMs may not be warranted.