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10-04-2012 | Cardiology | Article

Educating angina patients about ACS risk reduces stress testing


Free abstract

MedWire News: Patients experiencing chest pain who use a decision aid that evaluates their risk for acute coronary syndrome (ACS) are more likely to opt out of stress testing than those who undergo usual care, a study shows.

However, this decision does not adversely affect the results of their healthcare, report Erik Hess (Mayo Clinic College of Medicine, Rochester, Minnesota, USA) and colleagues in Circulation: Cardiovascular Quality and Outcomes.

"To avoid missing a diagnosis of heart attack, emergency physicians often admit patients to observation units for stress testing, even though patients are at a very low risk for heart attack," Hess explained in a press statement.

"This results in false positive test results, unnecessary additional procedures, exposure to radiation and increased cost."

Hess and team therefore investigated whether a web-based quantitative pretest probability calculator that estimates 45-day risk for ACS using data from initial emergency department (ED) presentation, examination, and laboratory tests, could reduce the number of patients admitted for stress testing.

The decision aid was administered to 101 patients and included a 100-person pictograph depicting the pretest probability of ACS and the available management options, including observation unit admission and stress testing, or follow up with a cardiologist within 72 hours.

Usual care was administered to 103 patients and included a discussion with a clinician about ED unit admission and urgent cardiac stress testing.

Compared with patients who underwent usual care, significantly more of those who used the decision aid correctly assessed their exact pretest probability of ACS within 45 days of their ED visit, at 1% versus 25%.

According to the OPTION (observing patient involvement) scale, which measured the quality of patient-clinician discussions and determined the degree of patient participation in the decision-making process, patients who used the decision aid had a significantly greater amount of involvement in their care decisions than those in the usual care arm, at 26.6% versus 7.0%.

Furthermore, a lower proportion of patients who used the decision aid decided to be admitted to the observation unit for stress testing than those who underwent usual care (58 vs 77%, p<0.0001).

Of note, there were no major adverse cardiac events after discharge in either group.

"This study suggests that low-risk patients don't necessarily want extensive testing once a heart attack has been ruled out," commented Hess.

"Informing patients of their risk and engaging them in the decision-making process may enable physicians and patients to work together to choose an approach to evaluation that is more in line with what patients want, without negatively affecting the results of their health care."

However, he pointed out that because the decision aid requires close collaboration between emergency physicians and cardiologists so that patients can receive follow-up care within 72 hours, its use will be "more difficult in healthcare settings with less reliable access to outpatient follow-up."

The results of this study must be confirmed by testing the decision aid in different EDs, he added.

MedWire ( is an independent clinical news service provided by Springer Healthcare Limited. © Springer Healthcare Ltd; 2012

By Piriya Mahendra

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