Written by Clay Smith
More intense follow-up noninvasive cardiac stress testing within 72 hours among patients with chest pain discharged from the ED was associated with greater major adverse coronary events (MACE) at 60 days, but this was mainly driven by more downstream procedures.
Why does this matter?
The AHA recommended noninvasive testing (NIT) for chest pain patients discharged from the ED within 72 hours until recently. Several studies found the promptness of follow-up was hit or miss and didn’t seem to impact outcomes, except that testing begat more downstream procedures.
Don’t stress over the stress test?
This was a retrospective review of a Kaiser-Permanente health system that included 210,948 chest pain patients ruled out for acute MI in the ED. There were differing referral intensities among the providers in pressing for follow up within the 72 hour window, which created a sort of natural experiment. They found that with the most intense, rapid referral for NIT, there was an association with increased 60-day MACE. But this was mainly driven by coronary revascularization procedures, not by MI, cardiac arrest, cardiogenic shock, or death. When results were stratified by (retrospectively calculated) HEART score, more rapid follow-up was associated with an increased odds of MACE in those with a score of 4 to 5. Ironically, those with the highest HEART scores and most intense, rapid follow up had the lowest odds of MACE. This all means that pushing hard for a cardiac stress test within 72 hours doesn’t seem to make a difference in cardiac outcomes.
Higher intensity of 72-h noninvasive cardiac test referral does not improve short-term outcomes among emergency department patients with chest pain. Acad Emerg Med. 2022 Jan 22. doi: 10.1111/acem.14448. Online ahead of print.