Stress testing for chest pain patients ‘should be based on pretest probability’
MedWire News: Most patients with low-risk chest pain undergo stress testing regardless of pretest probability of coronary artery disease (CAD), researchers say.
However, abnormal test results were uncommon and rarely acted upon, found Srikanth Penumetsa (Baystate Medical Center, Springfield, Massachusetts, USA) and team.
"Low-risk chest pain is a common cause of hospital admission, however to our knowledge, there are no guidelines regarding the appropriate use of stress testing in such cases," they write in the Archives of Internal Medicine.
The team conducted a retrospective cohort study of 2107 patients aged 21 years and older who were admitted to a tertiary care center with chest pain in 2007 and 2008.
Of these patients, 1474 (69.9%) underwent stress testing and the results were abnormal in 184 (12.5%) patients. An abnormal test result was defined as ischemia on electrocardiogram; reversible, fixed, or mixed defect on nuclear imaging; or wall motion abnormality on stress echocardiography.
Within 30 days, 22 (11.6%) patients with abnormal test results underwent cardiac catheterization, nine (4.7%) underwent revascularization, and two (1.1%) were readmitted for myocardial infarction.
Multivariate analysis revealed that chest pain patients younger than 70 years, those with private insurance (versus Medicare, Medicaid), and those who were admitted to a service covered by house staff had a significantly increased likelihood for having a stress test ordered, at relative risks of 1.12, 1.19, and 1.39, respectively.
Of patients with low (<10%) pretest probability for CAD, 68.0% underwent stress testing, but only 4.5% of these had abnormal test results. After adjusting for patient age, comorbidities, insurance status, and house staff coverage, intermediate (10‑90%) pretest probability for CAD was significantly associated with stress test ordering, at a relative risk of 1.41, compared with low pretest probability.
Penumetsa et al conclude: "Ordering stress tests based on pretest probability could improve efficiency without endangering patients."
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By Piriya Mahendra