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Noninvasive Testing in Patients With Chest Pain

Noninvasive Testing in Patients With Chest Pain To the Editor A recent article in JAMA Internal Medicine,1 later highlighted in a focused review,2 studied outcomes in emergency department chest pain patients with unremarkable electrocardiograms and biomarkers. Results suggest that noninvasive coronary artery disease (CAD) testing leads to more downstream tests and revascularizations compared with no testing, and at 6 months, myocardial infarction (MI) rates are similar for both nonivasive testing and no testing. While exclusion criteria were identical for both groups, respective patients were remarkably dissimilar. The testing group was 9 years older on average, with twice the prevalence of diabetes, hypertension, dyslipidemia, CAD, and hospital admission at index visit compared with the nontesting group (Table 1 in the article by Foy et al1). Baseline CAD likelihood and/or event risk was not reported. However, applying previous risk calculators for each group (by average age) to the data reported by Foy et al, the following respective likelihoods are found for no-test vs test patients: 3.3% vs 8.7% (The Duke Clinical Risk3), 0.7% vs 2.4% (Framingham4), and 0.8% vs 2.1% (2013 American College of Cardiology and American Heart Association5). By age alone, the testing group had a 2- to 3-fold higher baseline risk of obstructive CAD and events before considering the additional 2-fold burden of risk. The testing group vs the no-test group was diagnosed with more CAD, undergoing 2- to 3-fold more cardiac catheterizations (9.7% vs 3.4%) and revascularizations (2.5% vs 0.8%) (Table 2 and Figure 2 in the article by Foy et al1), reflecting their baseline risk profiles. Remarkably, despite predicted risks, there was no significant difference in 6-month MI rates (0.4% vs 0.3%) between the very-low-risk nontesting group and the higher-risk testing group (Table 2 and Figure 2 in the article by Foy et al1). Could noninvasive testing strategies have led to therapeutic measures that mitigated risk, placing tested patients at similar MI risk as their low-risk counterparts? Clinicians should not rely on diagnostic testing without considering baseline patient risk and how tests may perform accordingly. Moreover, comparative effectiveness depends on the populations being studied. If 2 populations do not share similar baseline risk, definitive conclusions cannot be drawn regarding the relative efficacy of risk reduction strategies. Foy et al1,2 suggest that chest pain patients may derive no benefit from noninvasive testing and imply that testing may subject patients to wasteful overdiagnosis where underlying CAD is unlikely to harm patients if left untreated. Coronary artery disease remains the most common cause of death and morbidity in the Western world.6 While efforts to eliminate wasteful use of noninvasive cardiac testing are justified,7 we may be treading a slippery slope by insinuating that detection and treatment of CAD is superfluous in all chest pain patients with unremarkable electrocardiograms and biomarkers. The data presented in this article1 suggest good outcomes with current standard of care noninvasive diagnostic testing in patients with appropriate pretest risk. Back to top Article Information Corresponding Author: Gregory R. Hartlage, MD, Department of Cardiovascular Services, University of South Florida College of Medicine, 2905 Aquilla St, Tampa, FL 33629 (ghartlagemd@gmail.com). Conflict of Interest Disclosures: None reported. References 1. Foy AJ, Liu G, Davidson WR Jr, Sciamanna C, Leslie DL. Comparative effectiveness of diagnostic testing strategies in emergency department patients with chest pain: an analysis of downstream testing, interventions, and outcomes. JAMA Intern Med. 2015;175(3):428-436.PubMedGoogle ScholarCrossref 2. Foy AJ, Filippone L. Chest pain evaluation in the emergency department. Med Clin North Am. 2015;99(4):835-847.PubMedGoogle ScholarCrossref 3. Pryor DB, Harrell FE Jr, Lee KL, Califf RM, Rosati RA. Estimating the likelihood of significant coronary artery disease. Am J Med. 1983;75:771-780.Google ScholarCrossref 4. Wilson PW, D’Agostino RB, Levy D, Belanger AM, Silbershatz H, Kannel WB. Prediction of coronary heart disease using risk factor categories. Circulation. 2013;97(18):1837-1847.Google ScholarCrossref 5. Goff DC Jr, Lloyd-Jones DM, Bennett G, et al. ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. Circulation. 2014;129(25)(suppl 2):S49-S73.Google ScholarCrossref 6. Mozaffarian D, Benjamin EJ, Go AS, et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics--2015 update: a report from the American Heart Association. Circulation. 2015;131(4):e29-e322.PubMedGoogle ScholarCrossref 7. Safavi KC, Li SX, Dharmarajan K, et al. Hospital variation in the use of noninvasive cardiac imaging and its association with downstream testing, interventions, and outcomes. JAMA Intern Med. 2014;174(4):546-553.PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Internal Medicine American Medical Association

Noninvasive Testing in Patients With Chest Pain

JAMA Internal Medicine , Volume 175 (10) – Oct 1, 2015

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Publisher
American Medical Association
Copyright
Copyright © 2015 American Medical Association. All Rights Reserved.
ISSN
2168-6106
eISSN
2168-6114
DOI
10.1001/jamainternmed.2015.4152
Publisher site
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Abstract

To the Editor A recent article in JAMA Internal Medicine,1 later highlighted in a focused review,2 studied outcomes in emergency department chest pain patients with unremarkable electrocardiograms and biomarkers. Results suggest that noninvasive coronary artery disease (CAD) testing leads to more downstream tests and revascularizations compared with no testing, and at 6 months, myocardial infarction (MI) rates are similar for both nonivasive testing and no testing. While exclusion criteria were identical for both groups, respective patients were remarkably dissimilar. The testing group was 9 years older on average, with twice the prevalence of diabetes, hypertension, dyslipidemia, CAD, and hospital admission at index visit compared with the nontesting group (Table 1 in the article by Foy et al1). Baseline CAD likelihood and/or event risk was not reported. However, applying previous risk calculators for each group (by average age) to the data reported by Foy et al, the following respective likelihoods are found for no-test vs test patients: 3.3% vs 8.7% (The Duke Clinical Risk3), 0.7% vs 2.4% (Framingham4), and 0.8% vs 2.1% (2013 American College of Cardiology and American Heart Association5). By age alone, the testing group had a 2- to 3-fold higher baseline risk of obstructive CAD and events before considering the additional 2-fold burden of risk. The testing group vs the no-test group was diagnosed with more CAD, undergoing 2- to 3-fold more cardiac catheterizations (9.7% vs 3.4%) and revascularizations (2.5% vs 0.8%) (Table 2 and Figure 2 in the article by Foy et al1), reflecting their baseline risk profiles. Remarkably, despite predicted risks, there was no significant difference in 6-month MI rates (0.4% vs 0.3%) between the very-low-risk nontesting group and the higher-risk testing group (Table 2 and Figure 2 in the article by Foy et al1). Could noninvasive testing strategies have led to therapeutic measures that mitigated risk, placing tested patients at similar MI risk as their low-risk counterparts? Clinicians should not rely on diagnostic testing without considering baseline patient risk and how tests may perform accordingly. Moreover, comparative effectiveness depends on the populations being studied. If 2 populations do not share similar baseline risk, definitive conclusions cannot be drawn regarding the relative efficacy of risk reduction strategies. Foy et al1,2 suggest that chest pain patients may derive no benefit from noninvasive testing and imply that testing may subject patients to wasteful overdiagnosis where underlying CAD is unlikely to harm patients if left untreated. Coronary artery disease remains the most common cause of death and morbidity in the Western world.6 While efforts to eliminate wasteful use of noninvasive cardiac testing are justified,7 we may be treading a slippery slope by insinuating that detection and treatment of CAD is superfluous in all chest pain patients with unremarkable electrocardiograms and biomarkers. The data presented in this article1 suggest good outcomes with current standard of care noninvasive diagnostic testing in patients with appropriate pretest risk. Back to top Article Information Corresponding Author: Gregory R. Hartlage, MD, Department of Cardiovascular Services, University of South Florida College of Medicine, 2905 Aquilla St, Tampa, FL 33629 (ghartlagemd@gmail.com). Conflict of Interest Disclosures: None reported. References 1. Foy AJ, Liu G, Davidson WR Jr, Sciamanna C, Leslie DL. Comparative effectiveness of diagnostic testing strategies in emergency department patients with chest pain: an analysis of downstream testing, interventions, and outcomes. JAMA Intern Med. 2015;175(3):428-436.PubMedGoogle ScholarCrossref 2. Foy AJ, Filippone L. Chest pain evaluation in the emergency department. Med Clin North Am. 2015;99(4):835-847.PubMedGoogle ScholarCrossref 3. Pryor DB, Harrell FE Jr, Lee KL, Califf RM, Rosati RA. Estimating the likelihood of significant coronary artery disease. Am J Med. 1983;75:771-780.Google ScholarCrossref 4. Wilson PW, D’Agostino RB, Levy D, Belanger AM, Silbershatz H, Kannel WB. Prediction of coronary heart disease using risk factor categories. Circulation. 2013;97(18):1837-1847.Google ScholarCrossref 5. Goff DC Jr, Lloyd-Jones DM, Bennett G, et al. ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. Circulation. 2014;129(25)(suppl 2):S49-S73.Google ScholarCrossref 6. Mozaffarian D, Benjamin EJ, Go AS, et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics--2015 update: a report from the American Heart Association. Circulation. 2015;131(4):e29-e322.PubMedGoogle ScholarCrossref 7. Safavi KC, Li SX, Dharmarajan K, et al. Hospital variation in the use of noninvasive cardiac imaging and its association with downstream testing, interventions, and outcomes. JAMA Intern Med. 2014;174(4):546-553.PubMedGoogle ScholarCrossref

Journal

JAMA Internal MedicineAmerican Medical Association

Published: Oct 1, 2015

References