CT Scans, Stress Tests Provide Little Benefit in Evaluation of Chest Pain Patients in ED
December 12th, 2017
In too many cases, unnecessary computed tomography (CT) scans and cardiac stress tests are used in patients presenting to the emergency department (ED) with chest pain, according to a new study.
The article in JAMA Internal Medicine, published concurrently with a presentation at the American Heart Association Scientific Sessions in Anaheim, CA, reports that overuse of the tests adds to healthcare costs without any clinical benefit.
The Washington University School of Medicine-led research describes a typical clinical evaluation as medical history, physical examination, an electrocardiogram (ECG), and biomarker assessment. Often, however, emergency physicians also order a CT scan or a cardiac stress test, they point out.
“Our study suggests that in the emergency room, stress testing and CT scans are unnecessary for evaluating chest pain in possible heart attack patients,” explained cardiologist and senior author David L. Brown, MD, a professor of medicine. “Patients don't do any better when given these additional tests. Our study is not a definitive randomized clinical trial, but it does suggest that we are overtesting and overtreating these patients.”
The current troponin blood test is much more sensitive than earlier ones, Brown noted. With previous blood tests, “a patient could be having a heart attack, and these older tests often would come back normal,” he said. “Doctors didn't trust the tests, so they looked for other ways to evaluate the patient. CT scans and stress tests were among the methods used. But now that the blood testing method is so much better, there is less reason to continue doing these screening tests in the emergency room.”
For the retrospective analysis of data from the randomized multicenter Rule Out Myocardial Ischemia/Infarction by Computer Assisted Tomography (ROMICAT-II) trial, researchers evaluated data for 1,000 patients who presented with chest pain to EDs at nine hospitals around the United States. Patients had a mean age of 54.4 and 48% were female.
The study team primarily analyzed how clinical evaluation plus noninvasive testing vs. clinical evaluation alone affected length of stay (LOS). Hospital admission, direct ED discharge, downstream testing, rates of invasive coronary angiography, revascularization, major adverse cardiac events (MACE), repeated ED visits or hospitalizations for recurrent chest pain at 28 days, and cost were all secondary outcomes. The investigators also looked at missed acute coronary syndrome (ACS) and cumulative radiation exposure during the index visit and follow-up period.
Results suggest that, during the 28-day study period, patients who underwent clinical evaluation alone experienced:
- a shorter LOS — 20.3 hours vs. 27.9 hours;
- lower rates of diagnostic testing and angiography — 2% vs. 11%;
- lower median costs $2,261.50 vs. $2584.30;
- less cumulative radiation exposure — 0 vs 9.9 m.
At the same time, lack of testing was associated with a lower rate of ACS diagnoses — 0% vs 9% — and less coronary angiography and percutaneous coronary intervention (PCI) during the index visit — 0% vs. 10% and 0% vs. 4%, respectively. However, study authors identified no difference in rates of PCI, coronary artery bypass surgery, return ED visits, or MACE during the follow-up period.