Written by Clay Smith
Stress testing within 72 hours of ED discharge in patients deemed low risk for ACS was completed in just 31.3% and was not associated with reduction in major adverse cardiac events (MACE) at 30 days.
Why does this matter?
AHA guidelines recommend an outpatient stress test be performed within 72 hours of ED discharge in patients with possible ACS deemed low risk who are discharged. But does this actually happen, and does it reduce risk of MACE?
Don’t stress about the test
This was a retrospective review of 24,459 patients with possible ACS evaluated in a southern California integrated healthcare system at 13 hospitals. Of these, 7,988 were supposed to complete outpatient stress testing, largely consisting of stress or pharmacologic ECG testing. Just 31.3% of these completed the test within the recommended 3 days. It was much harder for patients seen on Thursday or Friday to meet the 72-hour goal. MACE was low in all patients discharged from the ED, whether tested or not, with rates for all patients: “death 0.0%, acute myocardial infarction 0.7%, and revascularization 0.3%.” Compared to those with delayed or no outpatient stress testing, those tested within 3 days had no reduction in MACE at 30 days (OR 0.92; 95%CI 0.55 to 1.54). It’s hard to get patients timely outpatient stress testing, even within an integrated system like Kaiser Permanente. And since it appears that those with testing derived no benefit, it probably doesn’t matter.
See this Emergency Medicine Cases podcast on stress tests in the ED.
Do not miss Justin Morgenstern’s epic 4-part series on the evidence regarding stress testing.
Evaluation of Outpatient Cardiac Stress Testing After Emergency Department Encounters for Suspected Acute Coronary Syndrome. Ann Emerg Med. 2019 Apr 5. pii: S0196-0644(19)30054-X. doi: 10.1016/j.annemergmed.2019.01.027. [Epub ahead of print]
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Reviewed by Thomas Davis