Nicklaus P Ashburn1, Zachary P Smith2, Kale J Hunter2, Nella W Hendley2, Simon A Mahler3, Brian C Hiestand2, Jason P Stopyra2. 1. Department of Emergency Medicine, Wake Forest School of Medicine, Winston Salem, NC, United States. Electronic address: n.ashburn@wakehealth.edu. 2. Department of Emergency Medicine, Wake Forest School of Medicine, Winston Salem, NC, United States. 3. Department of Emergency Medicine, Wake Forest School of Medicine, Winston Salem, NC, United States; Departments of Epidemiology and Prevention and Implementation Science, Wake Forest School of Medicine, Winston Salem, NC, United States.
Abstract
BACKGROUND: The HEART Pathway identifies low-risk chest pain patients for discharge from the Emergency Department without stress testing. However, HEART Pathway recommendations are not always followed. The objective of this study is to determine the frequency and diagnostic yield of stress testing among low-risk patients. METHODS: An academic hospital's chest pain registry was analyzed for low-risk HEART Pathway patients (HEAR score ≤ 3 with non-elevated troponins) from 1/2017 to 7/2018. Stress tests were reviewed for inducible ischemia. Diagnostic yield was defined as the rate of obstructive CAD among patients with positive stress testing. T-test or Fisher's exact test was used to test the univariate association of age, sex, race/ethnicity, and HEAR score with stress testing. Multivariate logistic regression was used to determine the association of age, sex, race/ethnicity, and HEAR score with stress testing. RESULTS: There were 4743 HEART Pathway assessments, with 43.7% (2074/4743) being low-risk. Stress testing was performed on 4.1% (84/2074). Of the 84 low-risk patients who underwent testing, 8.3% (7/84) had non-diagnostic studies and 2.6% (2/84) had positive studies. Among the 2 patients with positive studies, angiography revealed that 1 had widely patent coronary arteries and the other had multivessel obstructive coronary artery disease, making the diagnostic yield of stress testing 1.2% (1/84). Each one-point increase in HEAR score (aOR 2.17, 95% CI 1.45-3.24) and being male (aOR 1.59, 95% CI 1.02-2.49) were associated with testing. CONCLUSIONS: Stress testing among low-risk HEART Pathway patients was uncommon, low yield, and more likely in males and those with a higher HEAR score.
BACKGROUND: The HEART Pathway identifies low-risk chest pain patients for discharge from the Emergency Department without stress testing. However, HEART Pathway recommendations are not always followed. The objective of this study is to determine the frequency and diagnostic yield of stress testing among low-risk patients. METHODS: An academic hospital's chest pain registry was analyzed for low-risk HEART Pathway patients (HEAR score ≤ 3 with non-elevated troponins) from 1/2017 to 7/2018. Stress tests were reviewed for inducible ischemia. Diagnostic yield was defined as the rate of obstructive CAD among patients with positive stress testing. T-test or Fisher's exact test was used to test the univariate association of age, sex, race/ethnicity, and HEAR score with stress testing. Multivariate logistic regression was used to determine the association of age, sex, race/ethnicity, and HEAR score with stress testing. RESULTS: There were 4743 HEART Pathway assessments, with 43.7% (2074/4743) being low-risk. Stress testing was performed on 4.1% (84/2074). Of the 84 low-risk patients who underwent testing, 8.3% (7/84) had non-diagnostic studies and 2.6% (2/84) had positive studies. Among the 2 patients with positive studies, angiography revealed that 1 had widely patent coronary arteries and the other had multivessel obstructive coronary artery disease, making the diagnostic yield of stress testing 1.2% (1/84). Each one-point increase in HEAR score (aOR 2.17, 95% CI 1.45-3.24) and being male (aOR 1.59, 95% CI 1.02-2.49) were associated with testing. CONCLUSIONS: Stress testing among low-risk HEART Pathway patients was uncommon, low yield, and more likely in males and those with a higher HEAR score.
Authors: Glenn N Levine; Eric R Bates; James C Blankenship; Steven R Bailey; John A Bittl; Bojan Cercek; Charles E Chambers; Stephen G Ellis; Robert A Guyton; Steven M Hollenberg; Umesh N Khot; Richard A Lange; Laura Mauri; Roxana Mehran; Issam D Moussa; Debabrata Mukherjee; Brahmajee K Nallamothu; Henry H Ting Journal: J Am Coll Cardiol Date: 2011-11-07 Impact factor: 24.094
Authors: Simon A Mahler; Kristin M Lenoir; Brian J Wells; Gregory L Burke; Pamela W Duncan; L Douglas Case; David M Herrington; Jose-Franck Diaz-Garelli; Wendell M Futrell; Brian C Hiestand; Chadwick D Miller Journal: Circulation Date: 2018-11-27 Impact factor: 29.690
Authors: Simon A Mahler; Chadwick D Miller; Judd E Hollander; John T Nagurney; Robert Birkhahn; Adam J Singer; Nathan I Shapiro; Ted Glynn; Richard Nowak; Basmah Safdar; Mary Peberdy; Francis L Counselman; Abhinav Chandra; Joshua Kosowsky; James Neuenschwander; Jon W Schrock; Stephen Plantholt; Deborah B Diercks; W Frank Peacock Journal: Int J Cardiol Date: 2012-10-30 Impact factor: 4.164
Authors: J H Pope; T P Aufderheide; R Ruthazer; R H Woolard; J A Feldman; J R Beshansky; J L Griffith; H P Selker Journal: N Engl J Med Date: 2000-04-20 Impact factor: 91.245
Authors: Karin H Humphries; May K Lee; Mona Izadnegahdar; Min Gao; Daniel T Holmes; Frank X Scheuermeyer; Martha Mackay; Andre Mattman; Eric Grafstein Journal: Acad Emerg Med Date: 2018-02-08 Impact factor: 3.451
Authors: Jason P Stopyra; Robert F Riley; Brian C Hiestand; Gregory B Russell; James W Hoekstra; Cedric W Lefebvre; Bret A Nicks; David M Cline; Kim L Askew; Stephanie B Elliott; David M Herrington; Gregory L Burke; Chadwick D Miller; Simon A Mahler Journal: Acad Emerg Med Date: 2018-07-19 Impact factor: 3.451
Authors: Kirsten E Fleischmann; Lee Goldman; Paula A Johnson; Richard A Krasuski; J Stephen Bohan; L Howard Hartley; Thomas H Lee Journal: J Thromb Thrombolysis Date: 2002-04 Impact factor: 2.300
Authors: Ezra A Amsterdam; J Douglas Kirk; Deborah B Diercks; William R Lewis; Samuel D Turnipseed Journal: J Am Coll Cardiol Date: 2002-07-17 Impact factor: 24.094
Authors: Henderson D McGinnis; Nicklaus P Ashburn; Brennan E Paradee; James C O'Neill; Anna C Snavely; Jason P Stopyra; Simon A Mahler Journal: Acad Emerg Med Date: 2022-03-31 Impact factor: 5.221
Authors: Nicklaus P Ashburn; Anna C Snavely; Ryan M Angi; James F Scheidler; Remle P Crowe; Henderson D McGinnis; Brian C Hiestand; Chadwick D Miller; Simon A Mahler; Jason P Stopyra Journal: Am J Emerg Med Date: 2021-11-30 Impact factor: 4.093