Major adverse cardiac events after ED evaluation of chest pain patients with advanced testing: systematic review and meta-analysis

First published: 06 November 2021



Our primary objective was to describe the risk of major adverse cardiac events (MACE) at 1 month, 6 months and 12 months after a negative coronary CTA (cCTA), electrocardiogram (ECG) stress test, stress echocardiography, and myocardial perfusion scintigraphy (MPS) in low to intermediate-risk patients.


Initially, 952 articles were identified for screening, 81 met criteria for full-text review, and once risk of bias was assessed, 33 articles were included in this meta-analysis. We utilized a random-effects model to assess pooled MACE event proportion for patients undergoing evaluation of ACS when risk stratified to a low to intermediate-risk category after undergoing standard testing. Heterogeneity analysis was performed using Cochrane’s Q test and I2 statistic.


Twenty-one studies evaluated follow up at 1 month with cCTA having a 0.09% (95CI 0.03% – 0.26%) pooled MACE compared to 0.23% (95CI 0.01% – 5.8%) of the exercise stress testing(p=1). MPS and cCTA had an overall event rate of 0.15% (95CI 0.06%-0.41%) at 6 months (I2 = 0%). At 12 months, a subgroup analysis found a pooled cCTA MACE of 0.16% (95CI 0.04% – 0.65%) compared to 1.68% (95CI 0.01% – 2.6%) for stress echocardiography with low within-group heterogeneity (I2 = 0%). Subgroup analysis of cCTA with no disease vs non-obstructive disease (<50% stenosis) did not find statistical difference in the MACE at both 1-month (0.17% (95CI 0.04% – 0.67%) vs 0.06% (95CI 0.01% – 0.34%)) and 12 months (0.44% (95CI 0.09% – 2.2% vs 0.54% (95CI 0.19% – 1.5%)).


Patients presenting with chest pain that have a coronary CTA showing <50% stenosis, negative ECG stress test, stress echocardiography or stress myocardial perfusion scan in the past 12 months, can be discharged without any further risk stratification if their ECG and troponin are reassuring given low MACE.

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