The so-called “provocative” testing advocated by the American Heart Association for every patient with chest pain of possible ischemic origin has been the thistle in our salad for many years. They are the nidus for the crystallization of countless chest-pain observation units in our Emergency Departments.
And, they are one of lowest-yield venues in medicine.
Last year, I reported on a set of 1,754 biomarker-negative patients undergoing stress testing in Rhode Island, only 20 of which were true positives. This latest report follows-up the stress testing outcomes from the ASPECT and ADAPT cohorts in New Zealand. Of the 1,483 patients enrolled with negative biomarkers, 749 ultimately underwent exercise tolerance testing – 32 of which were positive, 22 of such had stenosis of greater than 70%. Including index admission and 1-year follow-up of the study cohort, 20 of these received some form of revascularization (PCI or CABG). In addition, there were 66 equivocal and 103 submaximal stress tests contributing to a total of 70 episodes of invasive coronary angiography, 32 of which identified stenosis >70%.
This is slightly higher yield, overall, than the previously reported U.S. cohort. Most likely, this is due to patients in this study being almost a decade older – almost 60 years on average – and having median TIMI score of 2, compared with the U.S. stress test population having a TIMI of 0. But, clearly, a cohort referred for stress testing resulting in only a 4.8% initial revascularization, including just 36 of 93 referred for coronary angiography, is not an effective use of healthcare resources. And, this presumes the interventions performed as a result of stress testing provide some incremental morbidity or mortality benefit.
There are certainly patients for whom the various types of stress testing, non-invasive coronary angiography, and invasive angiography are each appropriate – but clearly we need to dramatically improve the specificity of our selection criteria.
“The incremental value of stress testing in patients with acute chest pain beyond serial cardiac troponin testing”