The Limited Utility of Routine Cardiac Stress Testing in Emergency Department Chest Pain Patients Younger Than 40 Years
Received 24 October 2008; received in revised form 12 December 2008; accepted 7 January 2009. published online 23 February 2009.
Study objective
This is a study designed to evaluate the utility of routine provocative cardiac testing in low-risk young adult (younger than 40 years) patients evaluated for an acute coronary syndrome in an emergency department (ED) setting.
Methods
This was a retrospective observational study of patients aged 23 to 40 years who were evaluated for acute coronary syndrome in an ED-based chest pain unit from March 2004 to September 2007. All patients had serial cardiac biomarker testing to rule out myocardial infarction and then underwent provocative cardiac testing to identify the presence of myocardial ischemia. Patients were excluded from the study if they had known coronary artery disease, had ECG findings diagnostic of myocardial infarction or ischemia, or self-admitted, or tested positive for cocaine use.
Results
Of the 220 patients who met inclusion criteria, 6 patients (2.7%; 95% confidence interval 1% to 5.8%) had positive stress test results. Among these 6 patients, 4 underwent subsequent coronary angiography that demonstrated no obstructive coronary disease, suggesting the initial provocative study was falsely positive. For the remaining 2 patients, no diagnostic angiography was performed. Discounting the patients who had negative angiography results, only 2 of 220 study patients (0.9%; 95% confidence interval 0.1% to 3.2%) had a provocative test result that was positive for myocardial ischemia.
Conclusion
In our study, a combination of age younger than 40 years, nondiagnostic ECG result, and 2 sets of negative cardiac biomarker results at least 6 hours apart identified a patient group with a very low rate of true-positive provocative testing. Routine stress testing added little to the diagnostic evaluation of this patient group and was falsely positive in all patients who consented to diagnostic coronary angiography (4 of 6 cases).
aDepartment of Emergency Medicine, Division of Emergency Critical Care, Mount Sinai School of Medicine, New York, NY
bDepartment of Emergency Medicine, Elmhurst Hospital, New York, NY
cDivision of Cardiology, Department of Internal Medicine, Mount Sinai School of Medicine, New York, NY
Address for correspondence: Luke K. Hermann, MD, Department of Emergency Medicine, Mount Sinai School of Medicine, One Gustave Levy Place, Box 1149, New York, NY 10029
Supervising editor: Keith A. Marill, MD
Author contributions: LKH conceived of the study, supervised data collection, and drafted the article. SDW provided significant revisions to the article, including the structure and content of the discussion and conclusions segments. WLD designed and implemented the data collection instrument that provided background patient information. WLD and MJH assisted with revisions to the article. MJH provided access to the results of all cardiac studies. LKH takes responsibility for the paper as a whole.
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The authors have stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement.
Publication date: Available online February 23, 2009.
ABSTRACT