Exercise Tolerance is Good Screening Test for Chest Pain Patients
Mayo Clinic researchers studying patients in the emergency department with acute chest pain report in the current issue of Mayo Clinic Proceedings that exercise treadmill testing (ETT) was often sufficient for evaluation.
Not all patients can be evaluated this way. However, patients who met the physician's criteria were able to be evaluated by the less costly method of exercise treadmill testing. Those who weren't candidates for this testing could be admitted to the hospital and didn't benefit very much from more costly stress imaging testing in the emergency department.
The evaluation of patients who come to the emergency department with chest pain is a major challenge. A system that evaluates symptoms and estimates the risk of each patient is useful in determining treatment protocols and the need for additional tests.
"Our strategy with exercise treadmill testing in selected patients helped us choose patients for hospital admission in a cost-effective and safe way," said Raymond Gibbons, M.D., Mayo Clinic cardiologist and one of the primary authors of the study.
The Mayo Clinic study looked at 212 intermediate-risk patients with unstable angina who were evaluated with chest pain units (CPU), a triage strategy to determine the severity of a patient's condition. Those patients were compared with 212 who were routinely admitted to Saint Marys Hospital in Rochester.
The researchers found that those who were eligible for the treadmill testing frequently had normal results and could be safely discharged from the emergency room without any significant events in the following six months. Those who were not eligible for the treadmill testing, such as those not capable of exercising, were frequently abnormal by stress imaging and usually admitted to the hospital.
"Referring this high-risk group for further stress imaging adds little benefit and is not cost-effective, primarily because of the high rate of admission after equivocal or abnormal results from stress imaging studies," said Dr. Gibbons.
Other authors of the study include: Gautam Ramakrishna, M.D.; Alan Zinsmeister, Ph.D.; Thomas Allison, Ph.D.; and Peter Smars, M.D., of Mayo Clinic. James Milavetz, M.D., is now with Utah Cardiology in Ogden, Roger Evans, PhD, is now a self-employed consultant in Rochester, Minn, and Michael Farkouh, M.D., is now with the New York University Medical Center.
In an editorial in the March issue of Mayo Clinic Proceedings, Ezra Amsterdam, M.D., and William Lewis, M.D., of the UC Davis School of Medicine and UC Davis Medical Center in Sacramento, Calif., note the challenge of providing optimal care while enhancing cost effectiveness and resource utilization for patients who are experiencing chest pain.
The editorial writers support as "more practical and focused" the study's conclusion that the "results suggest that a community hospital that is planning to set up a CPU may benefit more by developing expertise in exercise treadmill testing rather than in allocating resources to stress imaging."
Drs. Amsterdam and Lewis conclude that the optimal strategy for assessing patients with chest pain has not yet been realized, but investigators will continue toward that goal with studies such as the Mayo study.
A peer-review journal, Mayo Clinic Proceedings publishes original articles and reviews dealing with clinical and laboratory medicine, clinical research, basic science research and clinical epidemiology. Mayo Clinic Proceedings is published monthly by the Mayo Foundation for Medical Education and Research as part of its commitment to the medical education of physicians. The journal has been published for more than 75 years and has a circulation of 130,000 nationally and internationally. Copies of the articles are available online at www.mayoclinicproceedings.com
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