Noninvasive testing for chest pain may lead to increased invasive testing

1. Based on insurance claims data from emergency departments visits for chest pain, patients who did not undergo any testing for their complaint of chest pain had no more hospitalizations for myocardial infarctions compared to the patients who did undergo noninvasive cardiac testing.

2. However, those patients who underwent noninvasive testing were more likely to undergo cardiac catheterizations and revascularization procedures within a week after the initial visit, seemingly without benefit.

Evidence Rating Level: 2 (Good)       

Study Rundown: Emergency department visits related to chest pain are significant causes of health care expenditure, though mainly due to downstream spending. There are a number of different noninvasive tests that are utilized to risk stratify patients and determine who would most benefit from cardiac catheterization. This study sought to determine if there was an association between noninvasive cardiac testing versus no testing and the downstream effects for patients who presented to the ED with a complaint of chest pain. The results of the study suggested that patients who did not undergo any testing for their complaint of chest pain had no more hospitalizations for myocardial infarctions (MI) compared to the patients who did undergo noninvasive cardiac testing. However, those patients who underwent noninvasive testing were more likely to undergo cardiac catheterizations and revascularization procedures within a week after the initial visit, seemingly without benefit.

Strengths of the study include that all 50 states were represented, and a large sample size was included. However, since the rate of MIs was so low, it was difficult to identify significant differences amongst the different cohorts. Additionally, there were significant differences amongst patients how underwent testing compared to those who did, which adds significant bias to the data and makes it difficult to interpret (even though statistics were employed to account for this). Lastly, mortality data was not tracked in this study.

Click to read the study, published today in JAMA Internal Medicine

Click to read an accompanying editorial in JAMA Internal Medicine

Relevant Reading: Coronary CT angiography versus standard evaluation in acute chest pain.

In-Depth [retrospective cohort]: The study cohort was gathered from MarketScan Commercial Claims and Encounters data from 2011, which consisted of private insurance claims from medium- and large-sized hospitals from across the US. In the final analysis, 421,774 patients with a primary or secondary complaint of chest pain in the ED were included, of which 293,788 did not receive a noninvasive cardiac test and 127,986 did undergo testing. The noninvasive testing strategies in the study were exercise electrocardiography (EE), stress echocardiography (SE), myocardial perfusion scintigraphy (MPS), and coronary computed tomography angiography (CCTA).

Between the two cohorts (tested vs non-tested), there was no significant difference in the number of hospitalizations for myocardial infarctions in the ensuing 7 or 180-days. There was also a higher likelihood of undergoing cardiac catheterization within 7 days, regardless of which noninvasive testing modality was utilized compared to no testing – EE OR 1.63, SE OR 1.10, MPS OR 2.48, and CCTA OR 1.91. This was also true of coronary interventions for those who underwent testing compared to those who did not.

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Image: PD

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