Should Patients with Acute Chest Pain Undergo Noninvasive Testing After the Clinical Diagnosis is Made?

The use of noninvasive cardiac tests such as coronary computed tomographic angiography (CCTA) or stress testing for patients presenting to the emergency department with chest pain is not associated with a better clinical outcome when compared to the conventional method for diagnosing acute coronary syndrome, according to a recent study published in the Journal of American Medical Association.

The study is a secondary analysis of the ROMICAT-II trial which enrolled 1000 patients in the emergency departments of 9 U.S. hospitals. The patients had a follow-up of 28 days after their presentation into the emergency department with chest pain. Patients who had noninvasive tests in addition to the clinical evaluation were compared to those who only had clinical evaluation. The primary endpoint was the length of stay in the hospital, secondary endpoints included major adverse cardiovascular events (MACE) within 28 days, return to the emergency department, downstream testing, rates of revascularization in addition to other risk factors.  This study revealed that the use of noninvasive cardiac testing was associated with longer hospital stay , more radiation exposure , no difference in the rate of returning to the emergency department or the rate of MACE.

The current guidelines from the American Heart Association recommend performing these tests within three days of presentation while the European Society of Cardiology recommends performing the noninvasive tests in patients with negative biomarkers and ECG prior to proceeding to the invasive tests.

Dr. Gregory Curfman, Assistant Professor at Harvard Medical School and Editor-in-Chief of Harvard Health Publications commented in an accompanying editorial, “In most cases, the results of testing are negative in this low- to intermediate-risk population, and expensive resources may be consumed with no effect on clinical outcome”.

The authors stress that these tests should not be used as a diagnostic tool for acute coronary syndrome in the emergency department, which is a clinical diagnosis. The use of high sensitivity troponin provides a reasonable alternative with high sensitivity and a much lower cost, according to the authors.

The authors addressed some limitations of the study including the absence of randomization and the short duration of follow-up.

Dr. Curfman commented that “While the findings are suggestive that testing may safely be omitted in such patients, the results are not definitive.” He adds that “The study was not designed or powered to address this question, and patients were not randomized to testing or no testing.”.