Randomized comparison of a strategy of predischarge coronary angiography versus exercise testing in low-risk patients in a chest pain unit: In-hospital and long-term outcomes

Objectives This randomized trial compared a strategy of predischarge corona ry angiography (CA) with exercise treadmill testing (ETT) in low-risk patie nts in the chest pain unit (CPU) to reduce repeat emergency department (ED) visits and to identify additional coronary artery disease (CAD). Background Patients with chest pain and normal electrocardiograms (ECGs) ha ve a low likelihood of CAD and a favorable prognosis, but they often seek r epeat evaluations in EDs. Remaining uncertainty regarding their symptoms an d diagnosis may cause much of this recidivism. Methods A total of 248 patients with no ischemic ECG changes triaged to a C PU were randomized to CA (n = 123) or ETT (n = 125). All patients had a pro bability of myocardial infarction less than or equal to7% according to the Goldman algorithm, no biochemical evidence of infarction, the ability to ex ercise and no previous documented CAD. Patients were followed up for greate r than or equal to1 year and surveyed regarding their chest pain self-perce ption and utility of the index evaluation. Results Coronary angiography showed disease (greater than or equal to 50% s tenosis) in 19% and ETT was positive in 7% of the patients (p = 0.01). Duri ng follow-up (374 +/- 61 days), patients with a negative CA had fewer retur ns to the ED (10% vs. 30%, p = 0.0008) and hospital admissions (3% vs 16% p = 0.003), compared with patients with a negative/nondiagnostic ETT. The wa s more likely to consider their pain as cardiac-related (15% vs. 7%), to be unsure about its etiology (38% vs. 26%) and to judge their evaluation as n ot useful (39% vs. 15%) (p < 0.01 for all comparisons). Conclusions In low-risk patients in the CPU, a strategy of CA detects more CAD than ETT, reduces long-term ED and hospital utilization and yields bett er patient satisfaction and understanding (C) College of Cardiology.