scholarly journals Strategy for discharges from the stress test laboratory for ambulatory patients with chest pain/dyspnea in COVID-19 times

2021 ◽  
Vol 5 (3) ◽  
pp. 95
Author(s):  
Jesus Peteiro ◽  
Alberto Bouzas-Mosquera ◽  
Cayetana Barbeito-Caamaño ◽  
JoseManuel Vazquez-Rodriguez
Keyword(s):  
Chest Pain ◽  
Stress Test ◽  
Test Laboratory ◽  
Ambulatory Patients

P6150Clinical outcomes and downstream investigations following computed tomographic coronary angiography (CTCA) performed for evaluation of ambulatory patients with chest pain of recent onset

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
D Lehru ◽  
N Mortimer ◽  
S N Doshi ◽  
A Zaphiriou ◽  
S George ◽  
...  
Keyword(s):  
Chest Pain ◽  
Coronary Angiography ◽  
Stable Angina ◽  
Average Cost ◽  
Incidental Findings ◽  
Incidental Finding ◽  
Stress Test ◽  
High Sensitivity ◽  
Pain Clinic ◽  
Ambulatory Patients

Abstract Background National Institute of Clinical Excellence guideline (NICE, CG95) recommends CTCA as a 1st line diagnostic test for evaluation of ambulatory patients with suspected stable angina based on its high sensitivity and low cost. This has led to increasing demand for CTCA across the National Health Service (NHS) in order to comply with the NICE recommendation. Purpose We studied the utility and effectiveness of CTCA in the evaluation of ambulatory patients with suspected stable angina attending rapid access chest pain clinic (RACPC) in a large tertiary hospital in the UK. Methods The study included consecutive patients attending RACPC over a pre-specified period of 6-months who were suspected of having stable angina and hence, referred for CTCA. The data were collected on demographics, CTCA results including incidental finding and downstream investigations. All patients had a minimum of 12-months follow up for clinical outcomes. Results A total of 170 patients were referred for CTCA (mean age = 56.8 years, male = 53.5%) out of the 388 consecutive patients who were reviewed in the RACPC during the 6-month period. CTCA was non-diagnostic in 48/170 (28.2%) cases (Breathing artefact 35%, Severe Coronary Calcification 31%, Elevated heart rate/Ectopy 30%) while 63/170 (37.1%) of patients had incidental extra-cardiac findings. Amongst patients with incidental findings, 17/63 (27.0%) underwent further investigations. A total of 54/170 (31.7%) of patients were recommended to have downstream cardiac investigations such as a stress test (DSE/MRI/MPS) (23/170, 15.8%) while 31/170 (18.2%) were referred for invasive coronary angiography. Revascularisation procedures (PCI n=7.6%, CABG n=4.7%) were required in 21/170 (12.4%) patients. Based on 2017 NHS tariffs, overall average cost-per-patient with the initial CTCA approach was £122.11 excluding downstream investigations and £548.43 including the cost of downstream cardiac investigations. Incidental Findings after CTCA Conclusions Our study suggests that a CTCA based approach is associated with non-diagnostic information in at least 1:4 patients and incidental extracardiac findings in 1:3 patients. Further downstream cardiac investigations are required in around 1:3 patients after a CTCA carried out for evaluation suspected stable angina. The NICE recommendation is based on the low initial cost of CTCA and high sensitivity, however, taking in to account the additional cost of downstream investigations, the average cost per patient of this approach is significantly (4.5 times) higher. Acknowledgement/Funding None

scholarly journals Clinical judgement in chest pain: a case report 

2021 ◽  
Vol 15 (1) ◽  
Author(s):  
Mishita Goel ◽  
Shubhkarman Dhillon ◽  
Sarwan Kumar ◽  
Vesna Tegeltija
Keyword(s):  
Chest Pain ◽  
Coronary Artery ◽  
Tobacco Use ◽  
Stress Test ◽  
Artery Bypass ◽  
Pretest Probability ◽  
Clinical Judgement ◽  
Test Results ◽  
Cardiac Stress ◽  
History Of

Abstract Background Cardiac stress testing is a validated diagnostic tool to assess symptomatic patients with intermediate pretest probability of coronary artery disease (CAD). However, in some cases, the cardiac stress test may provide inconclusive results and the decision for further workup typically depends on the clinical judgement of the physician. These decisions can greatly affect patient outcomes. Case presentation We present an interesting case of a 54-year-old Caucasian male with history of tobacco use and gastroesophageal reflux disease (GERD) who presented with atypical chest pain. He had an asymptomatic electrocardiogram (EKG) stress test with intermediate probability of ischemia. Further workup with coronary computed tomography angiography (CCTA) and cardiac catheterization revealed multivessel CAD requiring a bypass surgery. In this case, the patient only had a history of tobacco use but no other significant comorbidities. He was clinically stable during his hospital stay and his testing was anticipated to be negative. However to complete workup, cardiology recommended anatomical testing with CCTA given the indeterminate EKG stress test results but the results of significant stenosis were surprising with the patient eventually requiring coronary artery bypass grafting (CABG). Conclusion As a result of the availability of multiple noninvasive diagnostic tests with almost similar sensitivities for CAD, physicians often face this dilemma of choosing the right test for optimal evaluation of chest pain in patients with intermediate pretest probability of CAD. Optimal test selection requires an individualized patient approach. Our experience with this case emphasizes the role of history taking, clinical judgement, and the risk/benefit ratio in deciding further workup when faced with inconclusive stress test results. Physicians should have a lower threshold for further workup of patients with inconclusive or even negative stress test results because of the diagnostic limitations of the test. Instead, utilizing a different, anatomical test may be more valuable. Specifically, the case established the usefulness of CCTA in cases such as this where other CAD diagnostic testing is indeterminate.

Abstract 115: Predictors Of A Positive Stress Test Among Patient Presenting To The Emergency Department With Chest Pain

2014 ◽  
Vol 7 (suppl_1) ◽  
Author(s):  
Taraka V Gadiraju ◽  
Jahnavi Sagi ◽  
Dev Basu ◽  
Srikanth Penumetsa ◽  
Michael Rothberg
Keyword(s):  
Emergency Department ◽  
Chest Pain ◽  
Stress Test ◽  
Tertiary Care ◽  
Face Validity ◽  
Pseudorandom Number Generator ◽  
Multivariable Model ◽  
Final Multivariable Model ◽  
Significant Difference ◽  
History Of

Objectives: Patients frequently present to the hospital with chest pain. Once myocardial infarction is ruled out based on EKG and cardiac enzymes, most patients undergo stress testing, but only few patients have a positive test. In ambulatory practice, age, sex and symptomatology can establish pretest probability of the coronary disease. However, there are no studies evaluating the predictors of a positive stress test in the emergency department (ED). We assessed predictors for a positive stress test in patients presenting to our hospital with chest pain. Methods: This is a case-control study conducted on a subset of patients admitted to our tertiary care center with chest pain between 2007 and 2009, and who had an inpatient stress test (n=1474). Using chart review, we identified 87 patients, whose stress tests were positive (abnormals), defined as presence of ischemia on EKG and/or imaging modalities. We then used a pseudorandom number generator to select 194 patients whose stress test results were normal (normals) for comparison. Clinical features of chest pain and CAD risk factors were abstracted from the medical record for comparison. A bivariable screening process was used to identify characteristics for inclusion in a multivariable predictive model. Sex and age were maintained in the model for face validity, and remaining covariates were removed in ascending order of their z-statistics until only those with a two-sided p-value of <0.10 remained. Stata 12.1 (Copyright 2011, StataCorp LP) was used for all analyses. Results: Patients with an abnormal stress test were older and more likely to be male and to have a history of vascular disease. Although patients with abnormal stress test were more likely to have history of hypertension, hyperlipidemia and current or ex-smoking, this difference was not statistically significant. Over half of the patients presented with non-cardiac chest pain and there was no significant difference in the chest pain characteristics between patients who had a normal and an abnormal stress test result. In the final multivariable model, when compared to the normals, abnormals were four times as likely to have a history of revascularization (OR 4.13, 95% CI 2.11, 8.09) and twice as likely to have a history of hyperlipidemia (OR 2.1, 95% CI 1.18, 3.79). They were also more likely to have an EKG suggestive of ischemia at presentation (OR 1.90, 95% CI 1.03, 3.53). Specificity of the model was 89%; sensitivity was 43%, and the c-statistic for the final multivariable model was 0.76, suggesting fair to good discrimination. Conclusions: Among patients presenting to the ED with chest pain, a past history of revascularization and hyperlipidemia and an EKG suggestive of ischemia may independently predict the likelihood of an abnormal stress test. Further validation of this model on an external dataset is necessary.

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

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.

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 ◽  
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.

scholarly journals Chest Pain and Exercise Induced Ischemia with Angiographically Insignificant Coronary Arterial Disease: Clinical Presentation and Follow-Up

1970 ◽  
Vol 6 (1) ◽  
pp. 27-31
Author(s):  
Md Khurshed Ahmed ◽  
Mohammad Salman ◽  
Md Ashraf Uddin Sultan ◽  
Md Abu Siddique ◽  
KMHS Sirajul Haque ◽  
...  
Keyword(s):  
Risk Factors ◽  
Cardiovascular Risk ◽  
Chest Pain ◽  
Stress Test ◽  
Exercise Stress Test ◽  
Exercise Stress ◽  
Coronary Angiogram ◽  
Ecg Changes ◽  
History Of

Angiography of patients with typical chest pain reveals normal epicardial coronary arteries in about 15-20%. ECG changes suggestive of myocardial ischemia during exercise also can be demonstrated in this subset of the patients. Total 58 patients (42 females) with mean age 42±7 years who were undergoing coronary angiogram in the Department of Cardiology, University Cardiac Center, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh from January 2005 to December 2009 were evaluated. The patients were recruited on the basis of presence of history of chest pain, with normal resting ECG and ischemia like ECG changes during exercise stress test. 32.8% patients had hypertension and 15.5% were diabetics, 19.0% had dyslipidemia and 6.9% had family history of ischemic heart disease. All the patients were having positive exercise stress test. Angiographic findings showed luminal irregularities in 29.3% patients, 15.5% patients had luminal stenosis less than 30% and rest had normal coronary angiogram. Follow up of the patients after one and six months of angiogram was done. After one month 63.8% patients remained symptomatic and after six months 63.3% patients remained symptomatic despite maximum medical management. The pathophysiology and appropriate management of this subset of the patients still remained a challenge for physicians. Optimum management of cardiovascular risk factors is very important issue in this group of patients.Key words: Angiography; Epicardial coronary arteries; Exercise stress test; Cardiovascular risk factors. DOI: 10.3329/uhj.v6i1.7187University Heart Journal Vol.6(1) 2010 pp.27-31

Role of the cycle ergometer stress test in chest pain with low-intermediate risk

2017 ◽  
Vol 263 ◽  
pp. e156-e157
Author(s):  
Paolo Scarinzi ◽  
Marta Biolo ◽  
Chiara Panzavolta ◽  
Lisa Benvegnù ◽  
Alois Saller ◽  
...  
Keyword(s):  
Chest Pain ◽  
Stress Test ◽  
Cycle Ergometer ◽  
Intermediate Risk

Diagnostic Value of the Updated Diamond and Forrester Score to Predict Coronary Artery Disease in Patients with Acute-Onset Chest Pain

Cardiology ◽  
2015 ◽  
Vol 133 (1) ◽  
pp. 10-17 ◽  
Author(s):  
Mathias Sørgaard ◽  
Jesper James Linde ◽  
Klaus Fuglsang Kofoed ◽  
Jørgen Tobias Kühl ◽  
Henning Kelbæk ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Coronary Artery Disease ◽  
Chest Pain ◽  
Coronary Artery ◽  
Diagnostic Accuracy ◽  
Stress Test ◽  
Photon Emission ◽  
Acute Onset ◽  
Emission Computed Tomography ◽  
Artery Disease

Objectives: In the recently updated clinical guidelines from the European Society of Cardiology on the management of stable coronary artery disease (CAD), the updated Diamond Forrester score has been included as a pretest probability (PTP) score to select patients for further diagnostic testing. We investigated the validity of the new guidelines in a population of patients with acute-onset chest pain. Methods: We examined 527 consecutive patients with either an exercise-ECG stress test or single-photon emission computed tomography, and subsequently coronary computed tomography angiography (CCTA). We compared the diagnostic accuracy of PTP and stress testing assessed by the area under the receiver operating characteristic curve (AUC) to identify significant CAD, defined as at least 1 coronary artery branch with >70% diameter stenosis identified by CCTA. Results: The diagnostic accuracy of PTP was significantly higher than the stress test (AUC 0.80 vs. 0.69; p = 0.009), but the diagnostic accuracy of the combination of PTP and a stress test did not significantly increase when compared to PTP alone (AUC 0.86 vs. 0.80; p = 0.06). Conclusions: PTP using the updated Diamond and Forrester Score is a very useful tool in risk-stratifying patients with acute-onset chest pain at a low-to-intermediate risk of having CAD. Adding a stress test to PTP does not appear to offer significant diagnostic benefit.

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

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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