Emergency Department Evaluation of Chest Pain Using Exercise Stress Echocardiography

Abstract

Abstract. Objective: Patients with a low risk of coronary artery disease (CAD) presenting to the emergency department (ED) with chest pain pose a diagnostic dilemma because a small percentage will suffer an acute myocardial infarction (MI) and sudden death. The authors conducted this study to determine whether exercise stress echocardiography (ESE) could be used to further support the safe discharge of these low-risk patients. Methods: A convenience sample of patients Ն30 years of age without a prior cardiac history who presented to an academic community hospital with chest pain, normal initial creatine kinase, and electrocardiography without ischemic changes underwent ESE within 6 Ϯ 1.7 hours (mean Ϯ SD). Abnormal ESE was defined as regional wall motion abnormality at rest or after exercise. The ED disposition and three-and six-month follow-up for cardiac events were recorded. This was a prospective observational cohort study. Results: Of a total of 149 eligible patients, 145 completed the study. The mean age (ϮSD) was 47 Ϯ 9 years; 56% were male. No adverse events were noted during ESE. Seven patients (5%) had abnormal ESE (2 with rest wall motion abnormalities and 5 with exercise-induced wall motion abnormalities). Five of the seven underwent cardiac catheterization; three had CAD. All patients received telephone follow-up at three months and six months. Of the 138 patients with a normal ESE, all were free of cardiac events at three months. One patient had a non-Q-wave MI at six months (negative predictive value = 99.3%, 95% CI = 97.8% to 100%). Conclusions: Exercise stress echocardiography can be used to evaluate low-risk chest pain patients in the ED. Patients with a normal ESE may be considered for discharge with minimal risk of sequelae.

Stress echo in chest pain unit: the SPEED trial

“…Results of the present study are consistent with a large, growing body of evidence suggesting the merits of stress testing for stratifying patients in chest pain unit [23][24][25][26][27][28]. In particular, a negative stress-imaging test has a very high negative predictive value in these patients.…”

Cost-Effectiveness of Coronary MDCT in the Triage of Patients with Acute Chest Pain

“…Patients who are at low risk for ACS because of negative initial cardiac biomarkers and normal or nondiagnostic ECG examinations, but in whom the source of chest pain is not readily identified, are a cohort whose management is notably inefficient [4][5][6][7]. The Funding for this study was provided through the Walker Fund of the Harvard Ph.D.…”

“…American College of Cardiology (ACC) and the American Heart Association (AHA) recommend further evaluation for these patients, but their hospitalizations typically result in benign diagnoses [5,8,9]. Because ACS is rare in the absence of coronary atherosclerotic plaque, several researchers have suggested that the incorporation of noninvasive CT coronary angiography may improve the triage of patients with acute chest pain and reduce health care costs [3,[10][11][12][13][14].…”

“…In 2004 alone, more than 6 million such visits occurred, and an estimated 30% of them resulted in hospitalization for suspected acute coronary syndrome (ACS), a condition that includes myocardial infarction (MI) and unstable angina [1,2]. Although some of the many patients who are admitted because of these suspicions are ultimately diagnosed with ACS, many are not, and inpatient care for negative evaluations is estimated to cost several billion dollars annually [3].Patients who are at low risk for ACS because of negative initial cardiac biomarkers and normal or nondiagnostic ECG examinations, but in whom the source of chest pain is not readily identified, are a cohort whose management is notably inefficient [4][5][6][7]. The Funding for this study was provided through the Walker Fund of the Harvard Ph.D.…”

Part 9: Acute Coronary Syndromes

“…Data from 5 studies of echocardiography performed in adult ED patients presenting with chest pain, negative cardiac enzymes, and non-diagnostic ECG's demonstrated decreased mean length of stay and reduced costs and predicted a low cardiovascular event rate (LOE 1 260 ; LOE 4 [261][262][263][264] ).…”