Major adverse cardiac events after emergency department evaluation of chest pain patients with advanced testing: Systematic review and meta‐analysis. (23rd November 2021)

• Record Type: Journal Article
• Authors: Mehta, Prayag; McDonald, Samuel; Hirani, Raiz; Good, Daniel; Diercks, Deborah
• Is Part Of: Academic emergency medicine. Volume 29:Number 6(2022)
• Page Start: 748
• Page End: 764
• Publication Date: 2021-11-23
• Subjects: coronary CTA -- ECG -- emergency department -- low‐risk chest pain -- MACE -- major adverse cardiac events -- meta‐analysis -- myocardial perfusion scintigraphy -- stress ECHO -- stress EKG -- stress testing -- systematic review -- TIMI; Emergency medicine -- Periodicals; 616.02505
• DOI: 10.1111/acem.14407
• Languages: English
• ISSNs: 1069-6563

Abstract

Abstract: Objectives: Our primary objective was to describe the risk of major adverse cardiac events (MACE) at 1, 6, and 12 months after a negative coronary computed tomography angiogram (cCTA), electrocardiogram (ECG) stress test, stress echocardiography, and myocardial perfusion scintigraphy (MPS) in low‐ to intermediate‐risk patients. Methods: Initially, 952 articles were identified for screening, 81 met criteria for full‐text review, and once risk of bias was assessed, 33 articles were included in this meta‐analysis. We utilized a random‐effects model to assess pooled MACE event proportion for patients undergoing evaluation of acute coronary syndrome (ACS) when risk stratified to a low‐ to intermediate‐risk category after undergoing standard testing. Heterogeneity analysis was performed using Cochrane's Q‐test and I 2 statistic. Results: Twenty‐one studies evaluated follow‐up at 1 month with cCTA having a 0.09% (95% confidence interval [CI] = 0.03% to 0.26%) pooled MACE compared to 0.23% (95% CI = 0.01% to 5.8%) of the exercise stress testing (p = 1). MPS and cCTA had an overall event rate of 0.15% (95% CI = 0.06% to 0.41%) at 6 months ( I 2 = 0%). At 12 months, a subgroup analysis found a pooled cCTA MACE of 0.16% (95% CI = 0.04% to 0.65%) compared to 1.68% (95% CI = 0.01% to 2.6%) for stress echocardiography with low within‐group heterogeneity ( I 2 = 0%). Subgroup analysis of cCTA with no disease versus nonobstructive disease (<50% stenosis) did not find statistical difference in the MACE at both 1 month (0.17% [95% CI = 0.04% to 0.67%] vs. 0.06% [95% CI = 0.01% to 0.34%]) and 12 months (0.44% [95% CI = 0.09% to 2.2% vs. 0.54% [95% CI = 0.19% to 1.5%]). Conclusions: Patients presenting with chest pain who have a coronary CTA showing < 50% stenosis, negative ECG stress test, stress echocardiography, or stress myocardial perfusion scan in the past 12 months can be discharged without any further risk stratification if their ECG and troponin are reassuring given low MACE.