Echocardiography, nuclear scintigraphy, and stress testing in the emergency department evaluation of acute coronary syndrome

Association of Early Stress Testing with Outcomes for Emergency Department Evaluation of Suspected Acute Coronary Syndrome

BACKGROUND

Professional society guidelines suggest early stress testing (within 72 hours) after an emergency department (ED) evaluation for suspected acute coronary syndrome (ACS). However, there is increasing concern that current practice results in over-testing without evidence of benefit. We test the hypothesis that early stress testing improves outcomes.

METHODS

We analyzed prospectively collected data from 9 EDs on patients with suspected ACS, 1999-2001. We excluded patients with an ED diagnosis of ACS. The primary outcome was 30-day major adverse cardiac events (MACEs), including all-cause death, acute myocardial infarction, and revascularization. We used the HEART score to determine pretest ACS risk (low, intermediate, and high). To mitigate potential confounding, patients with and without early stress testing were matched within pretest risk strata in a 1:2 ratio using propensity scores.

RESULTS

Of 7127 potentially eligible patients, 895 (13%) received early stress testing. The analytic cohort included 895 patients with early stress testing matched to 1790 without early stress testing. The overall 30-day MACE rate in both the source and analytic population was 3%. There were no baseline imbalances after propensity score matching (P > 0.1 for more than 30 variables). There was no association between early stress testing and 30-day MACE [odds ratio, 1.0; 95% confidence interval (CI), 0.6-1.7]. There was no effect modification by pretest risk (low: odds ratio, 1.0; 95% CI, 0.2-3.7; intermediate: 1.2; 95% CI, 0.6-2.6; high: 0.4; 95% CI, 0.1-1.6).

CONCLUSIONS

Early stress testing is not associated with reduced MACE in patients evaluated for suspected ACS. Early stress testing may have limited value in populations with low MACE rate.

Point of care cardiac ultrasound applications in the emergency department and intensive care unit--a review

The use of point of care echocardiography by non-cardiologist in acute care settings such as the emergency department (ED) or the intensive care unit (ICU) is very common. Unlike diagnostic echocardiography, the scope of such point of care exams is often restricted to address the clinical questions raised by the patient's differential diagnosis or chief complaint in order to inform immediate management decisions. In this article, an overview of the most common applications of this focused echocardiography in the ED and ICU is provided. This includes but is not limited to the evaluation of patients experiencing hypotension, cardiac arrest, cardiac trauma, chest pain and patients after cardiac surgery.