Emergency department evaluation of chest pain using exercise stress echocardiography

Objective: Patients with a low risk of coronary artery disease (CAD) presen ting to the emergency department (ED) with chest pain pose a diagnostic dil emma because a small percentage will suffer an acute myocardial infarction (MI) and sudden death. The authors conducted this study to determine whethe r exercise stress echocardiography (ESE) could be used to further support t he safe discharge of these low-risk patients. Methods: A convenience sample of patients greater than or equal to 30 years of age without a prior cardi ac history who presented to an academic community hospital with chest pain, normal. initial creatine kinase, and electrocardiography without ischemic changes underwent ESE within 6 +/- 1.7 hours (mean +/- SD). Abnormal ESE wa s defined as regional wall motion abnormality at rest or after exercise. Th e ED disposition and three- and six-month follow-up for cardiac events were recorded. This was a prospective observational cohort study. Results: Of a total of 149 eligible patients, 145 completed the study. The mean age (+/- SD) was 47 +/- 9 years; 56% were male. No adverse events were noted during ESE. Seven patients (5%) had abnormal ESE (2 with rest wall motion abnormal ities and 5 with exercise-induced wall motion abnormalities). Five of the s even underwent cardiac catheterization; three had CAD. All patients receive d telephone follow-up at three months and six months. Of the 138 patients w ith a normal ESE, all were free of cardiac events at three months. One pati ent had a non-Q-wave MI at six months (negative predictive value = 99.3%, 9 5% CI = 97.8% to 100%). Conclusions: Exercise stress echocardiography can b e used to evaluate low-risk chest pain patients in the ED. Patients with a normal ESE may be considered for discharge with minimal risk of sequelae.