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Early Noninvasive Cardiac Testing After Emergency Department Evaluation for Suspected Acute Coronary Syndrome

Educational Objective
To evaluate the effectiveness of early noninvasive cardiac testing (NIT) in reducing the risk of death or acute myocardial infarction within 30 days.
1 Credit CME
JAMA Internal Medicine
Published Online: October 5, 2020
Original Investigation
Aniket A. Kawatkar, PhD1;
Adam L. Sharp, MD1;
Aileen S. Baecker, PhD1;
Shaw Natsui, MD2;
Rita F. Redberg, MD3,4;
Ming-Sum Lee, MD5;
Maros Ferencik, MD6;
Yi-Lin Wu, MS1;
Ernest Shen, PhD1;
Chengyi Zheng, PhD1;
Visanee V. Musigdilok, MPH1;
Michael K. Gould, MD1;
Steve Goodacre, PhD7;
Praveen Thokala, PhD7;
Benjamin C. Sun, MD8
Author Affiliations
  • 1Research and Evaluation Department, Kaiser Permanente Southern California, Pasadena
  • 2National Clinician Scholars Program, Department of Emergency Medicine, University of California, Los Angeles
  • 3Division of Cardiology, Department of Medicine, School of Medicine, University of California, San Francisco
  • 4Editor, JAMA Internal Medicine
  • 5Division of Cardiology, Los Angeles Medical Center, Kaiser Permanente Southern California, Los Angeles
  • 6Knight Cardiovascular Institute, Oregon Health and Science University, Portland
  • 7School of Health and Related Research, The University of Sheffield, Sheffield, United Kingdom
  • 8Leonard Davis Institute of Health Economics, Department of Emergency Medicine, University of Pennsylvania, Philadelphia
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Key Points

Question  Is early noninvasive cardiac testing (NIT) after an emergency department (ED) evaluation for acute coronary syndrome more effective than not testing to reduce the risk of death or acute myocardial infarction (MI) within 30 days?

Findings  In a cohort study of 79 040 adults presenting to the ED with chest pain who had MI ruled out, early NIT was associated with a small (0.4%) but significant decrease in the absolute composite risk of death or MI. The number needed to treat was 250.

Meaning  Early NIT may reduce the risk of death or MI, but its value is questionable for most patients seen in the ED.

Abstract

Importance  Professional guidelines recommend noninvasive cardiac testing (NIT) within 72 hours of an emergency department (ED) evaluation for suspected acute coronary syndrome. However, there is inexact evidence that this strategy reduces the risk of future death or acute myocardial infarction (MI).

Objective  To evaluate the effectiveness of early NIT in reducing the risk of death or acute MI within 30 days.

Design, Setting, and Participants  This retrospective, multicenter cohort study within the Kaiser Permanente Southern California integrated health care delivery system compared the effectiveness of early noninvasive cardiac testing vs no testing in patients with chest pain and in whom acute MI was ruled out who presented to an ED from January 2015 to December 2017. Patients were followed up for up to 30 days after emergency department discharge.

Exposures  Noninvasive cardiac testing performed within 3 days of an ED evaluation for suspected acute coronary syndrome.

Main Outcomes and Measures  The primary outcome was composite risk of death or acute MI, within 30 days of an ED discharge.

Results  A total of 79 040 patients were evaluated in this study, of whom 57.7% were female. The mean (SD) age of the cohort was 57 (16) years, and 16 164 patients (21%) had completed early NIT. The absolute risk of death or MI within 30 days was low (<1%). Early NIT had the minor benefit of reducing the absolute composite risk of death or MI (0.4% [95% CI, −0.6% to −0.3%]), and, separately, of death (0.2% [95% CI, −0.2% to −0.1%]), MI (−0.3% [95% CI, −0.5% to −0.1%]), and major adverse cardiac event (−0.5% [95% CI, −0.7% to −0.3%]). The number needed to treat was 250 to avoid 1 death or MI, 500 to avoid 1 death, 333 to avoid 1 MI, and 200 to avoid 1 major adverse cardiovascular event within 30 days. Subgroup analysis revealed a number needed to treat of 14 to avoid 1 death or MI in the subset of patients with elevated troponin.

Conclusions and Relevance  Early NIT was associated with a small decrease in the risk of death or MI in patients admitted to the ED with suspected acute coronary syndrome, but this clinical strategy may not be optimal for most patients given the large number needed to treat.

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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

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Acute Coronary Syndromes Cardiology Emergency Medicine Ischemic Heart Disease Less is More
Article Information

Accepted for Publication: July 13, 2020.

Corresponding Author: Adam L. Sharp, MD, MS, Research and Evaluation Department, Kaiser Permanente Southern California, 100 S Los Robles Ave, Pasadena, CA 91101 (adam.l.sharp@kp.org).

Published Online: October 5, 2020. doi:10.1001/jamainternmed.2020.4325

Author Contributions: Dr Kawatkar had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Kawatkar, Sharp, Natsui, Redberg, Lee, Ferencik, Shen, Zheng, Gould, Goodacre, Thokala, Sun.

Acquisition, analysis, or interpretation of data: Kawatkar, Sharp, Baecker, Natsui, Lee, Ferencik, Wu, Shen, Zheng, Musigdilok, Thokala, Sun.

Drafting of the manuscript: Kawatkar, Baecker.

Critical revision of the manuscript for important intellectual content: Kawatkar, Sharp, Natsui, Redberg, Lee, Ferencik, Wu, Shen, Zheng, Musigdilok, Gould, Goodacre, Thokala, Sun.

Statistical analysis: Kawatkar, Baecker, Ferencik, Wu, Shen.

Obtained funding: Sharp, Ferencik, Wu, Goodacre, Sun.

Administrative, technical, or material support: Baecker, Ferencik, Zheng, Musigdilok, Thokala, Sun.

Supervision: Kawatkar, Sharp, Shen, Thokala, Sun.

Conflict of Interest Disclosures: Dr Kawatkar reported grants from the National Institutes of Health and the National Heart, Lung, and Blood Institute during the conduct of the study. Dr Sharp reported grants from National Institutes of Health and the National Heart, Lung, and Blood Institute during the conduct of the study. Dr Baecker reported grants from National Institutes of Health during the conduct of the study. Dr Ferencik reported grants from the National Institutes of Health during the conduct of the study. Dr Wu reported grants from the National Institutes of Health during the conduct of the study. Dr Zheng reported grants from National Institutes of Health during the conduct of the study. Dr Gould reported grants from the National Institutes of Health and the National Heart, Lung, and Blood Institute during the conduct of the study. Dr Goodacre reported grants from National Institute for Health during the conduct of the study. Dr Thokala reported grants from the University of Pennsylvania during the conduct of the study. Dr Sun reported grants from the National Institutes of Health and the National Heart, Lung, and Blood Institute during the conduct of the study, has served as expert witness for Winston & Strawn LLP and Fish & Richardson, was a consultant for Medtronic, and has received research support from Roche. Dr Goodacre has undertaken consultancy on behalf of the University of Sheffield for Creavo Industries. Dr Thokala has undertaken private consultancy for Roche. No other disclosures were reported.

Funding/Support: This study was funded by the National Heart, Lung, and Blood Institute of the National Institutes of Health under the R01 grant mechanism (R01HL134647).

Role of the Funder/Sponsor: The National Institutes of Health and the National Heart, Lung, and Blood Institute had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: Rita Redberg is editor of JAMA Internal Medicine, but she was not involved in any of the decisions regarding review of the manuscript or its acceptance. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Additional Contributions: The authors thank the patients of Kaiser Permanente for helping us improve care through the use of information collected through our electronic health record systems. We also appreciate the time and dedication of our project management team, Danielle Altman, MA, and Stacy Park, PhD, Kaiser Permanente Southern California, Pasadena, California; and Marie-Annick Yagapen, MPH, Oregon Health & Science University, Portland, Oregon. They were not compensated for their contributions to the article.

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