CLINICAL STUDY: CORONARY ANGIOGRAPHY
Randomized comparison of a strategy of predischarge coronary angiography versus exercise testing in low-risk patients in a chest pain unit: in-hospital and long-term outcomes
Christopher R. deFilippi, MD, FACCa,
Salvatore Rosanio, MD, PhDa,
Monica Tocchi, MDa,
Rohit J. Parmar, MD, FACCa,
Marjorie A. Potter, RN, BSNa,
Barry F. Uretsky, MD, FACCa and
Marschall S. Runge, MD, PhD, FACCa
a Department of Internal Medicine, Division of Cardiology, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
Manuscript received September 21, 2000;
revised manuscript received January 12, 2001,
accepted March 14, 2001.
Reprint requests and correspondence: Dr. Christopher deFilippi, Department of Medicine, Division of Cardiology, Room G3K63, 22 South Greene Street, Baltimore, Maryland 21201-1595
cdefilip{at}medicine.umaryland.edu
OBJECTIVES
This randomized trial compared a strategy of predischarge coronary angiography (CA) with exercise treadmill testing (ETT) in low-risk patients in the chest pain unit (CPU) to reduce repeat emergency department (ED) visits and to identify additional coronary artery disease (CAD).
BACKGROUND
Patients with chest pain and normal electrocardiograms (ECGs) have a low likelihood of CAD and a favorable prognosis, but they often seek repeat evaluations in EDs. Remaining uncertainty regarding their symptoms and diagnosis may cause much of this recidivism.
METHODS
A total of 248 patients with no ischemic ECG changes triaged to a CPU were randomized to CA (n = 123) or ETT (n = 125). All patients had a probability of myocardial infarction  7% according to the Goldman algorithm, no biochemical evidence of infarction, the ability to exercise and no previous documented CAD. Patients were followed up for  1 year and surveyed regarding their chest pain self-perception and utility of the index evaluation.
RESULTS
Coronary angiography showed disease (50% stenosis) in 19% and ETT was positive in 7% of the patients (p = 0.01). During follow-up (374 ± 61 days), patients with a negative CA had fewer returns to the ED (10% vs. 30%, p = 0.0008) and hospital admissions (3% vs. 16%, p = 0.003), compared with patients with a negative/nondiagnostic ETT. The latter group was more likely to consider their pain as cardiac-related (15% vs. 7%), to be unsure about its etiology (38% vs. 26%) and to judge their evaluation as not useful (39% vs. 15%) (p < 0.01 for all comparisons).
CONCLUSIONS
In low-risk patients in the CPU, a strategy of CA detects more CAD than ETT, reduces long-term ED and hospital utilization and yields better patient satisfaction and understanding of their condition.
|
Abbreviations and Acronyms
| | CA | = coronary angiography or angiogram | | CAD | = coronary artery disease | | CPU | = chest pain unit | | ECG | = electrocardiogram or electrocardiographic | | ED | = emergency department | | ETT | = exercise treadmill test or testing | | MI | = myocardial infarction |
|
This article has been cited by other articles:
|
|
|
|
 
J. Sanchis, V. Bodi, J. Nunez, L. Mainar, E. Nunez, P. Merlos, E. Rumiz, G. Minana, X. Bosch, and A. Llacer
Efficacy of Coronary Revascularization in Patients With Acute Chest Pain Managed in a Chest Pain Unit
Mayo Clin. Proc.,
April 1, 2009;
84(4):
323 - 329.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. A. Ladapo, U. Hoffmann, F. Bamberg, J. T. Nagurney, D. M. Cutler, M. C. Weinstein, and G. S. Gazelle
Cost-Effectiveness of Coronary MDCT in the Triage of Patients with Acute Chest Pain
Am. J. Roentgenol.,
August 1, 2008;
191(2):
455 - 463.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J Sanchis, X Bosch, V Bodi, N Bellera, J Nunez, B Benito, J Ordonez, L Consuegra, M Heras, and A Llecer
Combination of clinical risk profile, early exercise testing and circulating biomarkers for evaluation of patients with acute chest pain without ST-segment deviation or troponin elevation
Heart,
March 1, 2008;
94(3):
311 - 315.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
C. A. Geluk and F. Zijlstra
Gatekeeper for coronary angiography
Eur. Heart J.,
May 1, 2006;
27(9):
1127 - 1128.
[Full Text]
[PDF]
|
|
|
|
|
|
|
J Sanchis, V Bodi, A Llacer, J Nunez, L Consuegra, M J Bosch, V Bertomeu, V Ruiz, and F J Chorro
Risk stratification of patients with acute chest pain and normal troponin concentrations
Heart,
August 1, 2005;
91(8):
1013 - 1018.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
B. A. Schaer, D. Jenni, P. Rickenbacher, C. Graedel, J.-L. Crevoisier, H.-U. Iselin, and M. Pfisterer
Long-term Performance of a Simple Algorithm for Early Discharge After Ruling Out Acute Coronary Syndrome: A Prospective Multicenter Trial
Chest,
April 1, 2005;
127(4):
1364 - 1370.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
K. F Fox
Investigation and management of chest pain
Heart,
January 1, 2005;
91(1):
105 - 110.
[Full Text]
[PDF]
|
|
|
|
|
|
|
L. Goldman and A. J. Kirtane
Triage of Patients with Acute Chest Pain and Possible Cardiac Ischemia: The Elusive Search for Diagnostic Perfection
Ann Intern Med,
December 16, 2003;
139(12):
987 - 995.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
R. Bholasingh, J. H. Cornel, O. Kamp, J. P. van Straalen, G. T. Sanders, J. G. P. Tijssen, V. A. W. M. Umans, C. A. Visser, and R. J. de Winter
Prognostic value of predischarge dobutamine stress echocardiography in chest pain patients with a negative cardiac troponin T
J. Am. Coll. Cardiol.,
February 19, 2003;
41(4):
596 - 602.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
P. C Wyer
Predischarge coronary angiography was better than exercise testing for reducing hospital use after low-risk chest pain
Evid. Based Med.,
January 1, 2002;
7(1):
14 - 14.
[Full Text]
[PDF]
|
|
|
|
|
|
|
Coronary Angiography for Low-Risk Patients with Chest Pain?
Journal Watch Cardiology,
August 31, 2001;
2001(831):
3 - 3.
[Full Text]
|
|
|
|
|
|
|
How Should Low-Risk Patients with Chest Pain Be Evaluated?
Journal Watch (General),
August 3, 2001;
2001(803):
4 - 4.
[Full Text]
|
|
|
|
|
|
|
W. R. Lewis and E. A. Amsterdam
Defining the role of chest pain units
J. Am. Coll. Cardiol.,
June 15, 2001;
37(8):
2050 - 2052.
[Full Text]
[PDF]
|
|
|
|
