For chest-pain triage in the ED, stress echo offers alternative to coronary CT

Reuters Health Information: For chest-pain triage in the ED, stress echo offers alternative to coronary CT

For chest-pain triage in the ED, stress echo offers alternative to coronary CT

Last Updated: 2018-06-26

By Lorraine L. Janeczko

NEW YORK (Reuters Health) - Stress echocardiography (SE) may be a good alternative to coronary computed tomography angiography (CCTA) when triaging patients with chest pain in the emergency department (ED), a new study suggests.

"When we compared stress echocardiography and CCTA, we saw that stress echocardiography was able to discharge more patients who came to the emergency department for chest pain and in a faster timeframe," Dr. Jeffrey M. Levsky of Montefiore Medical Center and Albert Einstein College of Medicine in New York City told Reuters Health by phone.

"Triage and fast decision-making are the order of the day, so it was surprising that stress echo, which is sometimes considered slower, was so good in this role," he added.

Dr. Levsky and colleagues compared CCTA with SE in patients who presented to an urban academic emergency department with low-to-intermediate-risk acute chest pain, no known coronary artery disease and a negative initial serum troponin level. Their findings were published online June 13 in JACC Cardiovascular Imaging.

The team randomly assigned 400 consecutive patients to either immediate CCTA or immediate SE. The participants averaged 55 years of age, 43% were women and most belonged to ethnic minorities (46% Hispanic, 32% African American).

At presentation, 39 (19%) of CCTA patients and 22 (11%) of SE patients were hospitalized (P=0.026). The median length of stay in the ED for discharged patients was 5.4 hours for patients who underwent CCTA and 4.7 hours for those who underwent SE (P<0.001). The median length of stay in the hospital was also shorter for SE patients (34 hours vs. 58 hours, P=0.002).

During a median follow-up of 24 months, 11 major adverse cardiovascular events were reported in the CCTA group compared with seven in the SE group (P=0.47).

The median and mean complete initial work-up radiation exposures were 6.5 mSv and 7.7 mSv, respectively, in the CCTA group versus 0 mSv and 0.96 mSv in the SE group (P<0.001).

"A lot of people look at coronary CCTA as the up-and-coming method for making a diagnosis quickly in the emergency department setting. Stress echo is a bit of a forgotten test that people don't consider as seriously for this job," Dr. Levsky said.

"In our typical urban practice in the Bronx, our patients are very multiethnic and diverse. It's always important to see how these tests perform in the real world," he added.

Dr. Levsky said that the single recruitment site was a limitation of the study.

"A strength of our study," he added, "is that the trial was randomized and that the patients were followed for two years after their test. In many emergency department trials, patients are followed for just 30 days. We care much more about what happens over the long term. That's a big difference."

"It seems that CCTA results in more procedures on patients, such as cardiac catheterization and coronary artery bypass surgery," Dr. Levsky observed. "We'd like to know if these procedures are really helping people. In some situations these procedures are life-saving. At other times, when we do more procedures, unfortunately, they don't help patients."

During the trial, the authors also developed a registry of patients who didn't meet the trial's inclusion criteria or refused to participate in the trial.

"The registry does not have the constraints of the strict entry and exclusion criteria of the randomized trial. We are studying the registry patients to get an idea about how the tests performed in the wider population," he said.

"In our decision making, we should have a good balance between the radiation concerns, which favor stress echocardiography, and the comprehensiveness of how much we think we need to evaluate the patient at the present time," he explained. "Coronary CT gives us much more information about subclinical heart disease and other potential chest pain causes."

In a phone interview, Dr. Pamela S. Douglas of the Duke Clinical Research Institute of Duke University in Durham, North Carolina, commended the inclusion of minority racial and ethnic groups in the trial.

"But the small size is a concern, and the authors weren't clear about what the patients were hospitalized for," said Dr. Douglas, who wrote an editorial about the study.

"I think there are many 'best' tests to do in many patient settings. We should use the available test that fits the question being asked for that patient - whether it's a diagnostic or a prognostic question - as well as that fits the patient's characteristics," she noted. "I'm in favor of precision testing, where the test choice is tailored to the individual rather than the one-size-fits-all, always doing the same test, whether it's stress echo or CT."


JACC Cardiovasc Imaging 2018.

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