Abstract 324: Ankle Brachial Index as a Predictor for Abnormal Cardiovascular Stress Test and Cardiovascular Outcomes

Background: The combination of ankle brachial index (ABI) and other risk stratification tools has been evaluated previously. However baseline ABI in patients admitted for chest pain prior to stress testing to predict increased probability of abnormal stress test and MACE (major cardiovascular adverse events) has not been studied. Methods: Patients (n= 342) admitted for chest pain with normal or unchanged electrocardiogram and negative troponin T who were referred for myocardial perfusion study were enrolled in this prospective observational study and followed for one year. The first part of the study was to assess if an abnormal ABI increases the probability of an abnormal stress test and the second part was to measure one-year outcome for MACE (Angina, MI, CHF, TIA/Stroke and deaths) based on their stress test and ABI results. Multivariable logistic regression modeling is used to interpret the data. Results: In our study population 83% of the patients had Framingham risk score less than 20. Twenty-nine percent of the patients with normal ABI and 40% of the patients with abnormal ABI had abnormal stress test. The difference is statistically insignificant. After adjusting for different variables abnormal ABI was found to have stronger correlation with MACE (Odds ratio 2.9, p 0.01, CI 1.2 - 6.7) as compared to abnormal stress test (Odds ratio 0.92, p 0.84 CI 0.3 - 2.1). Conclusion: In our study cohort an abnormal ABI, irrespective of the stress test results, was an independent predicator of MACE at one year. We can conclude that there is very weak temporal relationship between abnormal ABI and abnormal stress test in low risk population and asymptomatic peripheral vascular disease is a strong independent predictor of MACE, even in this low risk population. We can also conclude that ABI during stress testing can be used for risk stratification. Future studies may need more power in this low risk population.

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Abstract 363: Chest Pain Observation Unit: Does Post-Discharge Stress Testing Influence Physician Management Decisions?

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.7.suppl_1.363 ◽

2014 ◽

Vol 7 (suppl_1) ◽

Author(s):

Yasser Khalil ◽

Martin E Matsumura ◽

Maida Abdul-Latif ◽

Prasant Pandey ◽

Melvin Schwartz

Keyword(s):

Chest Pain ◽

Risk Stratification ◽

Stress Testing ◽

Stress Test ◽

Multivariate Regression Analysis ◽

The United States ◽

Observation Unit ◽

Management Decisions ◽

Post Discharge ◽

Effective Manner

Background: Chest pain (CP) accounts for approximately 6 million emergency visits per year in the United States. There is growing interest in strategies to effectively risk stratify pts for coronary artery disease (CAD) related events in a cost-effective manner. The use of chest pain observation units followed by early stress testing is frequently employed in these pts. However the utility of stress testing in this population is not well defined, and the effect of stress test results on subsequent management decisions is a topic of controversy. In the present study we examined the relationship of stress myocardial perfusion imaging (MPI) results to physician decisions regarding ccath in a single community teaching hospital. Methods: Retrospective study of 426 pts undergoing a chest pain observation strategy over a 24 month period. Pt eligible for the program had CP deemed possibly related to CAD but no diagnostic ECG changes and negative TnI measurements x2. All pts underwent outpt. stress MPI within 72 hours of discharge. Pts saw a cardiologist the day of stress MPI who reviewed the CP history, MPI results, and made decisions regarding further risk stratification. Demographic and medical history was collected from the pts chest pain observation unit record. Multivariate regression analysis was used to determine significant independent variables related to physician decisions regarding further risk stratification. Results: Of 426 pts who underwent outpt stress MPI, 71(16.7%) were positive for ischemia, and 16 (22.5% of +MPI) underwent cath with reperfusion performed in 8 (5PCI, 3 CABG, 11.3% of +MPI). Of the 355 pts with negative stress MPI, 5(1.4% of -MPI) underwent cath with reperfusion performed in 2 (2PCI, 0 CABG, 0.5% of -MPI). A MLR model suggested only stress MPI results were independently predictive of the use of ccath for risk stratification. Conclusion: Stress MPI was an important factor in physician decision-making regarding the need for ccath in pts managed in a chest pain observation unit. The rate of +MPI and subsequent use of ccath in our institution supports MPI as an appropriate step in risk stratification of low to moderate risk CP pts triaged through a CP observation unit.

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Emergency department patient compliance with follow-up for outpatient exercise stress testing: a randomized controlled trial

CJEM ◽

10.1017/s1481803500015463 ◽

2007 ◽

Vol 9 (06) ◽

pp. 435-440 ◽

Cited By ~ 24

Author(s):

Doug Richards ◽

Nazanin Meshkat ◽

Jaqueline Chu ◽

Kevin Eva ◽

Andrew Worster

Keyword(s):

Chest Pain ◽

Stress Testing ◽

Stress Test ◽

Intervention Group ◽

Exercise Stress Test ◽

Low Risk ◽

Exercise Stress ◽

Exercise Stress Testing ◽

Control Group

ABSTRACTIntroduction:Numerous patients are assessed in the emergency department (ED) for chest pain suggestive of acute coronary syndrome (ACS) and subsequently discharged if found to be at low risk. Exercise stress testing is frequently advised as a follow-up investigation for low-risk patients; however, compliance with such recommendations is poorly understood. We sought to determine if compliance with follow-up for exercise stress testing is higher in patients for whom the investigation is ordered at the time of ED discharge, compared with patients who are advised to arrange testing through their family physician (FP).Methods:Low-risk chest pain patients being discharged from the ED for outpatient exercise stress test and FP follow-up were randomized into 2 groups. ED staff ordered an exercise stress test for the intervention group, and the control group was advised to contact their FP to arrange testing. The primary outcome was completion of an exercise stress test at 30 days, confirmed through both patient contact and stress test results. Patients were unaware that our primary interest was their compliance with the exercise stress testing recommendations.Results:Two-hundred and thirty-one patients were enrolled and baseline characteristics were similar between the 2 groups. Completion of an exercise stress test at 30 days occurred in 87 out of 120 (72.5%) patients in the intervention group and 60 out of 107 (56.1%) patients in the control group. The difference in compliance rates (16.4%) between the 2 groups was statistically significant (χ2= 6.69,p< 0.001) with a relative risk of 1.29 (95% confidence interval 1.18–1.40), and the results remained significant after a “worst case” sensitivity analysis involving 4 control group cases lost to follow-up. When subjects were contacted by telephone 30 days after the ED visit, 60% of those who were noncompliant patients felt they did not have a heart problem and that further testing was unnecessary.Conclusion:When ED staff order an outpatient exercise stress test following investigation for potential ACS, patients are more likely to complete the test if it is booked for them before ED discharge. After discharge, many low-risk chest pain patients feel they are not at risk and do not return to their FP for further testing in a timely manner as advised. Changing to a strategy of ED booking of exercise stress testing may help earlier identification of patients with coronary heart disease.

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49 The use of CT coronary angiography following exercise stress testing in a low risk population presenting to a chest pain service

Heart ◽

10.1136/heartjnl-2015-308621.49 ◽

2015 ◽

Vol 101 (Suppl 5) ◽

pp. A26.1-A26

Author(s):

P Wheen ◽

S Ingram ◽

N Kelly ◽

B Loo

Keyword(s):

Chest Pain ◽

Coronary Angiography ◽

Stress Testing ◽

Ct Coronary Angiography ◽

Low Risk ◽

Exercise Stress ◽

Exercise Stress Testing ◽

Risk Population

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Abstract 13996: Does Copeptin Provide Additional Risk Stratification in Chest Pain Patients With a Mild Troponin Elevation?

Circulation ◽

10.1161/circ.130.suppl_2.13996 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Nicholas Marston ◽

Kevin Shah ◽

Christian Mueller ◽

Sean Xavier-Neath ◽

Robert Christenson ◽

...

Keyword(s):

Chest Pain ◽

Risk Stratification ◽

Odds Ratio ◽

Acute Chest Pain ◽

High Sensitivity ◽

Study Cohort ◽

Troponin Elevation ◽

Improve Risk Stratification ◽

Pain Patients ◽

Rule Out

Introduction: Copeptin has demonstrated a role in early rule out for acute myocardial infarction in combination with a negative troponin. However, the value of copeptin in patients with a positive troponin is not established. Hypothesis: The addition of a baseline copeptin at chest pain presentation will improve risk stratification in patients with mild troponin elevation. Methods: The multi-center CHOPIN trial enrolled 2071 acute chest pain patients. All subjects with ST segment elevations were excluded from this analysis. Of the remaining patients, 124 had a mildly elevated troponin (defined by < 2x URL) and were included in the study cohort. Baseline cTnI and copeptin levels were drawn on presentation, and another cTnI at 2 hours. Copeptin ≤14 pmol/l and troponin deltas ≤10% from baseline were considered positive. Two independent blinded cardiologists adjudicated AMI diagnosis. The value of a baseline copeptin in this cohort was assessed using AMI incidence, odds ratio, sensitivity, and negative predictive value (NPV). Results: Of the 124 patients in the study cohort, 73 (59%) had an elevated copeptin and an associated AMI incidence of 25% (18 AMIs). The remaining 51 patients (41%) were copeptin negative and diagnosed with 3 AMIs, an incidence of 5.9% (p = 0.006, figure 1). A positive copeptin increased the likelihood of AMI diagnosis with an odds ratio of 5.3 (95% CI: 1.5-19.2). The sensitivity and NPV for AMI were 86% and 94%, both of which were higher than the delta troponin (table 1). When an initial copeptin was combined with the delta troponin the sensitivity and NPV for AMI improved to 100%. Conclusion: Use of copeptin in chest pain patients with mild troponin elevation provides further risk stratification. The combination of copeptin with a delta troponin may aid in earlier AMI rule out in this subset of patients. This approach could be especially relevant as the increasing use of high sensitivity troponin assays leads to greater rates of mild troponin elevations.

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Abstract 16592: The Diamond-Forrester Criterion Significantly Overestimates the Risk of Obstructive Coronary Artery Disease in Patients Presenting to the Emergency Department With Low-Risk Chest Pain

Circulation ◽

10.1161/circ.130.suppl_2.16592 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Todd Lecher ◽

William R Davidson ◽

Andrew Foy

Keyword(s):

Risk Factors ◽

Emergency Department ◽

Chest Pain ◽

Stress Echocardiography ◽

Stress Test ◽

Pretest Probability ◽

Low Risk ◽

High Cholesterol ◽

Observation Unit ◽

Diamond Forrester

Introduction: We sought to (1) classify patients who underwent stress echocardiography in an emergency department observation unit based on their pretest probabilities of obstructive CAD using the Diamond-Forrester criterion, (2) to compare observed versus expected frequencies of obstructive CAD based on the Diamond-Forrester risk categories of low (<25%), intermediate (25-75%), and high (>75%) pretest probability of disease, and (3) to test the association of traditional cardiovascular risk factors (age, gender, hypertension, diabetes, high cholesterol, and smoking) with obstructive CAD. METHODS: Retrospective review of the electronic medical record for patients who presented to the emergency department with chest pain and underwent observation followed by stress echocardiography between the period January 1, 2012 to December 31, 2012. Patients were classified as low, intermediate, or high risk for obstructive CAD using the Diamond-Forrester criterion. Main outcome measures were stress echocardiography results as well as receipt of cardiac catheterization and results. RESULTS: A total of 504 patients were included in the final analysis. Overall, 4.8% had a positive stress test and only 1.2% had angiographic evidence of obstructive CAD. In each category of risk, the observed frequency of obstructive CAD was significantly lower than expected. Having a high pretest probability as defined by the Diamond-Forrester criterion was significantly associated with obstructive CAD. Age, gender, diabetes, hypertension, high cholesterol, and smoking were not independently associated with evidence of obstructive CAD; nor were any composites of these risk factors. CONCLUSIONS: The traditional Diamond-Forrester criterion significantly overestimates the probability of obstructive CAD in ED observation unit patients. Reliance on the Diamond-Forrester criterion and other traditional risk factors associated with obstructive CAD in the outpatient setting could lead to faulty Bayesian reasoning, overuse of non-invasive imaging, and improper interpretation of test results in an ED population of low-risk chest pain patients. Further work is required to determine an optimal risk-assessment strategy for this patient population.

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Low-risk Chest Pain Patients Younger Than 40 Years Do Not Benefit From Admission and Stress Testing

Critical Pathways in Cardiology ◽

10.1097/hpc.0b013e3182a75e3f ◽

2013 ◽

Vol 12 (4) ◽

pp. 201-203 ◽

Cited By ~ 3

Author(s):

Anthony M. Napoli ◽

Steven Tran ◽

Jing Wang

Keyword(s):

Chest Pain ◽

Stress Testing ◽

Low Risk ◽

Pain Patients

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Abstract 359: Lack Of Blood Pressure Augmentation During Stress Testing Is Associated With Increased Mortality.

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.6.suppl_1.a359 ◽

2013 ◽

Vol 6 (suppl_1) ◽

Author(s):

Geoffrey D’Cruz ◽

Ashish Rastogi ◽

Neil Yager ◽

Amarinder Bindra ◽

Steven A Fein ◽

...

Keyword(s):

Blood Pressure ◽

Chest Pain ◽

Stress Echocardiography ◽

Stress Testing ◽

Systolic Function ◽

Stress Test ◽

Care Center ◽

Tertiary Care ◽

History Of ◽

Response To Exercise

Objective: We investigated long-term outcomes associated with hypertensive response to exercise in patients with chest pain referred for stress echocardiography. Methods: Records of 404 patients with normal baseline LV systolic function (45% females, mean age 60+/-11 years, baseline SBP 136+/-20 mmHg, 26% with CAD, 4% with CHF, 39% with hypertension, 13% with diabetes mellitus, 5% with peripheral vascular disease, 21% with history of smoking or active smoking, 43% on beta-blockers, 23% on ACE-inhibitors/ARBs) referred for chest pain evaluation with stress echocardiography at a single tertiary care center were reviewed. Demographics, clinical data, and outcomes were collected. Median length of followup was 35+/-0.3 months. Patients were divided into four groups depending on their maximum blood pressure during exercise (greater or less than 180mmHg) and whether they achieved their age-adjusted target heart rate. Results: Contrary to the expectations, hypertensive response to exercise was not associated with the increased mortality (Table). Instead, lack of blood pressure augmentation during exercise and low double product were predictive of increased mortality. History of CHF (p=0.0003) and/or PVD (p=0.001) were the strongest predictors of failure to augment blood pressure during stress testing. Conclusions: Failure to augment systolic blood pressure during exercise appears to be associated with increased mortality. Although ischemia on echocardiography and reduced exercise capacity are the stress test outcomes traditionally associated with poor prognosis, failure to augment blood pressure during exercise may be an important predictor of mortality as well. Additional studies of this subject are needed.

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Abstract 17369: Addressing Missed Opportunities for Cardiometabolic Primary Prevention of Veterans Referred for Stress Testing

Circulation ◽

10.1161/circ.142.suppl_3.17369 ◽

2020 ◽

Vol 142 (Suppl_3) ◽

Author(s):

Ysanne Johnson ◽

Sheila M Mattei ◽

Matthew Burg ◽

Judith L Meadows

Keyword(s):

Risk Reduction ◽

Stress Testing ◽

Stress Test ◽

Standard Of Care ◽

Low Risk ◽

Stress Tests ◽

Missed Opportunities ◽

Presenting Symptoms ◽

Reduction Strategies ◽

Risk Reduction Strategies

Introduction: Patients presenting to stress testing have a high prevalence of cardiometabolic risk factors (RF) which are not at guideline supported goals. Referral to stress testing is often a patient’s first presentation to CV care and represents a missed opportunity for delivery of risk reduction strategies. Hypothesis: Implementation of a cardiometabolic prevention initiative for cardiology-naïve patients referred to stress testing will result in improved delivery of guideline-directed prevention care. Methods: A consecutive prospective cohort of patients who underwent stress testing (12/1/2019-1/31/2020) after implementation of a linked cardiometabolic prevention referral for those with low risk stress tests was compared to a retrospective standard of care (SOC) cohort (9/1/2019-10/1/2019) from a single center Veterans Hospital. Outcomes assessed were change in CV risk reduction care at 90 days following stress test. Results: Of 181 patients, 62.5% were naïve to cardiology specialty care, had >1 CV risk factor not meeting guideline goals, 6% had typical angina as presenting symptoms, and greater than 70% of stress tests were normal or low risk. Baseline CV RF were common and failed to reach goals in SOC and intervention cohorts respectively with LDL above goal (40 vs. 33%), stage 1 or greater hypertension (67 vs 81%), Diabetes with HgA1c > 7 (48 vs. 21%), overweight or obese (68 vs. 79%), current tobacco (11 vs. 12%), and elevated mean 10-year ASCVD risk (32 vs.20%). At 90 days, 28% of SOC cohort had intensification of CV prevention care as compared to 76% of intervention cohort (X 2 26.8, p<0.05). Conclusions: A stress testing setting represents a valuable opportunity to deliver cardiometabolic prevention care. Integration of risk reduction strategies is imperative to shift from cardiac disease management to patient centered health promotion.

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