Contrast-Enhanced Stress Echocardiography and Myocardial Perfusion Imaging in Patients Hospitalized With Chest Pain: A Randomized Study

Representation of Older Adults and Women in Randomized Trials of Non-Invasive Imaging for Chest Pain

Background

Non-invasive imaging is widely used both for initial diagnosis and to guide management of ischemic heart disease (IHD). Older adults and women with IHD may have different responses to imaging as well as to treatments and outcomes that follow compared with younger adults and men. We aimed to study the representation of older adults and women in randomized controlled trials (RCT) of non-invasive imaging among patients with acute and stable chest pain.

Methods

We conducted a systematic search to identify RCTs evaluating non-invasive, imaging-guided diagnosis and management for IHD that were published before September 1, 2023. Participation-to-Prevalence Ratio (PPR) was estimated for women and age subgroups of <65, 65-74, ≥75 years. PPR of <0.8, 0.8-1.2, and >1.2 indicated underrepresentation, appropriate representation, and overrepresentation, respectively.

Results

Among 53 RCTs, sex and age breakdown were available in 53 (n=55,893) and 21 trials (n=35,503), respectively. The median age across all trials was 57.4 years [IQR: 55.0- 60.2]. Participants aged <65 years were overrepresented with a median PPR 2.13 [IQR: 1.73- 2.43], while those aged 65-74 years and ≥75 years were underrepresented with median PPRs of 0.74 [IQR: 0.56-0.83] and 0.21 [IQR: 0.11-0.33], respectively. Women were adequately represented with a median PPR of 1.2 [1.06-1.32].

Conclusion

While women were appropriately represented, adults 65 years or older, especially those ≥75 years, were under-represented in these trials. Future RCTs on non-invasive imaging should target enrollment of older adults to ensure generalizability of results to this growing population.

CLINICAL PERSPECTIVE

In a systematic review of 53 randomized controlled trials of non-invasive imaging for chest pain published before September 1, 2023 (n=55,893 participants), adults aged 65 years and older, especially those aged 75 years and above, were significantly underrepresented, whereas women had representation proportional to prevalence estimates. These findings highlight an urgent need to increase enrollment of older adults in future imaging trials to ensure broader applicability and relevance of study results.

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Evaluation of Noninvasive Diagnostic Techniques in Identifying Coronary Artery Disease: A Systematic Review

Background

Coronary artery disease (CAD) poses a significant global health burden, necessitating optimal diagnostic strategies for risk assessment and management. This study systematically reviews randomized controlled trials (RCTs) comparing different noninvasive imaging modalities for CAD evaluation, focusing on their subsequent invasive outcomes and major adverse cardiac events (MACEs).

Methods

A comprehensive electronic search was conducted across multiple databases, identifying 24 relevant RCTs published between 2010 and 2023. Key outcomes assessed included downstream referral to invasive testing, MACE rates, cost-effectiveness, and hospitalization outcomes.

Results

The majority of included RCTs focused on comparing coronary computed tomography angiography (CCTA) with alternative imaging techniques. While CCTA is often associated with increased invasiveness, it demonstrates slightly better MACE rates, cost-effectiveness, and hospitalization outcomes compared to other imaging modalities.

Conclusion

Continued investigation into alternative noninvasive diagnostic methods for CAD is essential to advance clinical practice and optimize patient care. By exploring new strategies beyond CCTA and leveraging technological innovations, health-care providers can improve diagnostic precision, mitigate procedural risks, and ultimately enhance outcomes for individuals with CAD.

ACR Appropriateness Criteria® Chronic Chest Pain-High Probability of Coronary Artery Disease: 2021 Update

Management of patients with chronic chest pain in the setting of high probability of coronary artery disease (CAD) relies heavily on imaging for determining or excluding presence and severity of myocardial ischemia, hibernation, scarring, and/or the presence, site, and severity of obstructive coronary lesions, as well as course of management and long-term prognosis. In patients with no known ischemic heart disease, imaging is valuable in determining and documenting the presence, extent, and severity of obstructive coronary narrowing and presence of myocardial ischemia. In patients with known ischemic heart disease, imaging findings are important in determining the management of patients with chronic myocardial ischemia and can serve as a decision-making tool for medical therapy, angioplasty, stenting, or surgery. This document summarizes the recent growing body of evidence on various imaging tests and makes recommendations for imaging based on the available data and expert opinion. This document is focused on epicardial CAD and does not discuss the microvascular disease as the cause for CAD. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Improving Atraumatic Chest Pain Evaluation in an Urban, Safety-net Hospital Through Incorporation of a Modified HEART Score

Atraumatic chest pain is a common emergency department (ED) presentation and the American College of Cardiology and American Heart Association recommends stress testing within 72 hours. The HEART score predicts major adverse cardiac events (MACE) in ED populations and does not require universal stress testing. An evaluation based solely on history, electrocardiography, and biomarkers, therefore, is an attractive approach to risk stratification in resource-limited settings. The HEART score has not been previously evaluated in a safety net hospital setting. We therefore implemented an interdisciplinary clinical care guideline utilizing the HEART score to stratify patients presenting to our inner-city hospital. During a 6-month study period, 1170 patients were evaluated (521 before and 649 after implementation). Among the 998 patients with confirmed follow-up 6-weeks after the index ED encounter, the prevalence of MACE (all-cause mortality, acute myocardial infarction, or coronary revascularization) was 0% [95% confidence interval (CI), 0%-1%] for low, 9% (95% CI, 7%-12%) for moderate, and 52% (95% CI, 39%-65%) for high-risk groups. Guideline implementation significantly increased admissions (+12%, 95% CI, 7%-17%) primarily in the moderate risk group (+38%, 95% CI, 29%-47%), but significantly decreased median ED length of stay (-37 minutes, 95% CI, 17-58). It also led to an increase in stress testing among moderate and high-risk patients (+10%, 95% CI, 0%-19%). In conclusion, the HEART score effectively stratified risk of MACE in a safety net population, improved evaluation consistency, and decreased ED length of stay. However, implementation was associated with an increase in hospitalizations and stress testing. Although the American Heart Association/American College of Cardiology guideline regarding atraumatic chest pain in the ED recommends universal noninvasive testing, the value of this approach, particularly in conjunction with the HEART score is uncertain in safety net hospitals. Further evaluation of the costs and clinical advantages of this approach are warranted.