More Cardiac Testing ≠ Better (aka Verschlimmbessern)

Written by Cliff Freeman

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There is limited gain to repeating advanced cardiac testing for low to intermediate risk ED patients if the patient has had negative testing within the previous twelve months. It is reasonable to evaluate these patients with troponin and EKG and, if reassuring, avoid further testing.

Why does this matter?
Coronary artery disease is a leading cause of death in the United States, and it is often the ED physician’s job to decide who is at risk for this and who isn’t. With 14% of patients presenting to the ED with chest pain requiring admission, the looming question that remains is how to safely disposition those who do not require admission.

If at first you succeed, don’t test again
The authors performed a systematic review and meta-analysis analyzing the risk of Major Adverse Cardiac Events (MACE) for one year for patients with a negative coronary CTA, ECG stress test, stress echo, or myocardial perfusion scintigraphy if determined to be low- to intermediate- risk. This was defined as a TIMI score of ≤ 5 or a HEART score of ≤ 6. Overall, the rate of MACE within 12 months was less than 2% for all advanced testing modalities. Considering this, if these patients present to the ED with chest pain within 12 months of their prior advanced testing, there is little to gain with repeat advanced testing. This is consistent with the newest AHA guidelines regarding the workup of patients with chest pain.

Editor’s note: Tim, I knew that word you taught me would come in handy. Verschlimmbessern means making something worse by trying to improve it. ~Clay

Source
Major adverse cardiac events after emergency department evaluation of chest pain patients with advanced testing: Systematic review and meta-analysis. Acad Emerg Med. 2021 Nov 6. doi: 10.1111/acem.14407. Epub ahead of print.

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