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Abstract

Background: Evaluation and disposition of low-risk chest pain (CP) patients in the emergency department (ED) is time consuming and expensive. Low-risk CP often results in hospital admission to rule out myocardial infarction, which leads to additional costs and delays. Objective: Our aim was to assess whether an immediate exercise stress echocardiogram (IESE) in the ED will allow safe, efficient, and cost-effective evaluation and discharge of patients with low-risk CP. Methods: Low-risk CP patients (TIMI [Thrombolysis in Myocardial Infarction] score 0-1) presenting to the ED with normal electrocardiogram, no history of coronary artery disease, and negative troponin T received IESE. We followed these patients for major adverse cardiac events and compared them to a control cohort of similar-risk patients admitted with traditional care at 1 and 6 months. Results: We enrolled 216 patients, 117 IESE and 109 control. We obtained follow-up at 1 and 6 months in 94% of the IESE group and 88% in the control group. There was no difference in diagnostic catheterization or percutaneous coronary intervention between the 2 groups (6.0% and 1.7% vs. 6.4% and 1.8%; p = 0.89). Median time from triage to discharge was significantly shorter with IESE (572.6 min vs. 1466.0 min), resulting in significantly lower cost ($4380.50 vs. $6191.70). There were no adverse events related to IESE or early discharge. Conclusions: In our study, IESE for low-risk CP patients presenting to the ED has the potential to be equally safe, more expeditious, and more cost effective than admission to an observation unit.

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... Ward [38] 2010 In patients with high suspicion for pulmonary embolism but low likelihood of mortality, starting the diagnostic workup with US to assess for deep vein thrombosis and proceeding with only selective CT scanning is costeffective 22 Melnikow [39] 2016 In patients with suspected kidney stones randomized to initial POCUS, radiology US, or CT there were no significant differences in either outcome or cost 14 Sternberg [40] 2017 An assessment of over 10,000 cases of acute renal colic showed that if US was ordered at the initial visit, overall imaging cost and radiation exposure were lower than if CT scan was ordered initially 9 Wyrick [44] 2008 Myocardial contrast echocardiography in the ED on selected chest pain patients may be cost-effective through the prevention of unnecessary admissions 16 Jasani [45] 2018 Patients with low-risk chest pain discharged after stress echocardiography in the ED have lower costs and similar health outcomes compared to similar patients admitted to the hospital 8 Baugh [46] 2019 Large variation exists in ordering practices for tests on older patients with syncope in the ED, with CT head and echocardiogram standing out as expensive tests with relatively low yield 11 Gc [47] 2019 In a modeled scenario based on pilot data, the use of tissue Doppler evaluation of diastolic dysfunction in patients with non-ST elevation acute coronary syndrome produced overall cost-savings by decreasing length of stay acute flank pain had mixed findings. One study suggested no efficiency gains with US use due to high-numbers of subsequent CT orders, and another found that using US as the initial radiology modality decreases costs and radiation exposure despite a 20% subsequent use of CT to further evaluate patients [39,40]. ...
... Four studies assessed echocardiography in the emergency care setting [44][45][46][47]. Three of the studies focused on decreasing hospitalization using US to provide earlier risk-stratification of patients with acute chest pain or acute cardiac issues [44,45,47]. ...
... Four studies assessed echocardiography in the emergency care setting [44][45][46][47]. Three of the studies focused on decreasing hospitalization using US to provide earlier risk-stratification of patients with acute chest pain or acute cardiac issues [44,45,47]. One study assessed the cost-effectiveness of a variety of emergency department modalities to evaluate syncope in older patients, finding that CT head and echocardiography where among the most expensive and least revealing tests that are commonly ordered [46]. ...
Article
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Background The use of ultrasound (US) in emergency departments (ED) has become widespread. This includes both traditional US scans performed by radiology departments as well as point-of-care US (POCUS) performed by bedside clinicians. There has been significant interest in better understanding the appropriate use of imaging and where opportunities to enhance cost-effectiveness may exist. The purpose of this systematic review is to identify published evidence surrounding the cost-effectiveness of US in the ED and to grade the quality of that evidence. Methods We performed a systematic review of the literature following Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Studies were considered for inclusion if they were: (1) economic evaluations, (2) studied the clinical use of ultrasound, and (3) took place in an emergency care setting. Included studies were critically appraised using the Consolidated Health Economic Evaluation Reporting Standards checklist. Results We identified 631 potentially relevant articles. Of these, 35 studies met all inclusion criteria and were eligible for data abstraction. In general, studies were supportive of the use of US. In particular, 11 studies formed a strong consensus that US enhanced cost-effectiveness in the investigation of pediatric appendicitis and 6 studies supported enhancements in the evaluation of abdominal trauma. Across the studies, weaknesses in methodology and reporting were common, such as lack of sensitivity analyses and inconsistent reporting of incremental cost-effectiveness ratios. Conclusions The body of existing evidence, though limited, generally demonstrates that the inclusion of US in emergency care settings allows for more cost-effective care. The most definitive evidence for improvements in cost-effectiveness surround the evaluation of pediatric appendicitis, followed by the evaluation of abdominal trauma. POCUS outside of trauma has had mixed results.
... 1 Among the available modalities for diagnosing CAD in either ambulatory or emergency settings, stress echocardiography is proven as a cost-effective and safe functional test in appropriately selected patients. [2][3][4][5][6] Even though stress echocardiography has a high negative predictive value (NPV), 7 the factors that predict a worse outcome in the setting of a normal study are not well-defined. In addition to its diagnostic value, the echocardiographic findings and stress-induced changes in those variables have been previously used for risk stratification of patients with a possibility of CAD. ...
... In addition to its diagnostic value, the echocardiographic findings and stress-induced changes in those variables have been previously used for risk stratification of patients with a possibility of CAD. 4,6,8 Reduced functional capacity, left ventricular dysfunction and higher peak wall motion score index during stress echocardiography can be indicative of less favorable prognosis. [9][10][11] Though, these factors make the test positive and do not apply to patients with a normal study. ...
Article
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Introduction: Stress echocardiography is a safe and cost-effective method of evaluating the patients with suspected coronary artery disease (CAD). However, the risk factors of an adverse cardiovascular event after a normal exercise (ESE) or dobutamine (DSE) stress echocardiography are not well established. Methods: A cohort of 705 patients without previous history of CAD and a negative ESE/DSE was studied. All studies were performed in a high-volume echocardiologic laboratory and interpreted by two experienced echocardiography-trained cardiologists. Patients with inconclusive studies and those with an evidence of myocardial ischemia were excluded. Demographic, echocardiographic and hemodynamic findings were recorded. Patients were followed for at least 2 years. Independent predictors of major adverse cardiovascular events (MACE) were determined by regression analysis. Results: During a period of 55.7±17.5 months, MACE occurred in 35 (5.0%) of patients. Negative predictive value (NPV) of DSE was 89.2%, which was significantly less than 96.5% for ESE in predicting the occurrence of MACE (P = 0.001). MACE occurred more frequently among older (≥65 years) men with preexisting diabetes, hypertension, and/or hyperlipidemia. During ESE, a higher maximum blood pressure*heart rate product for the achieved level of metabolic equivalent (METS) of tasks was also an independent predictor of MACE. Conclusion: Inability of patients to undergo traditional ESE that led to the choice of using DSE alternative reduces the NPV of the stress echocardiography among patients without previous history of CAD. A modest rise of heart rate and blood pressure in response to increased level of activity serves as favorable prognostic value and improves the NPV of stress echocardiography.
... Immediate stress echocardiography has been shown to be equally as safe and more efficient in the triage and risk stratification of low-risk chest pain patients in the ED when compared to admission to an observation unit [61]. Several head-to-head comparisons of stress echocardiography to other modalities have also shown promising results. ...
Article
Patients presenting with chest pain and related symptoms account for over 6 million emergency department (ED) visits in the United States annually. However, less than 5% of these patients are ultimately diagnosed with acute coronary syndrome (ACS). ED clinicians face the diagnostic challenge of promptly identifying and treating these high-risk patients amidst the overwhelming majority of lower-risk patients for whom further testing and/or treatment is either unnecessary or non-urgent. To assist with and expedite risk stratification and decision-making in this challenging clinical scenario, diagnostic tools like clinical risk scores and high-sensitivity serum biomarkers have been incorporated into care algorithms within the ED. In this narrative review, we discuss how these tools impact the appropriate use of cardiovascular imaging in the initial assessment of patients presenting to the ED with possible ACS.
... However, its utility has been limited to places with such expertise and resources to perform this test, which has undoubtedly curtailed its clinical utility as most studies using contrast perfusion have originated in the research setting. Therefore, even when these newly added imaging modalities are unavailable, SE still remains mostly useful when assessing low-risk chest pain cases [16]. Furthermore, SE not only should be routinely considered as valuable for routine assessment of either chest pain or for preoperative evaluations, but it also might be useful in identifying MVD, particularly if no other imaging options are available, as clearly stated in the latest 2019 European Society of Cardiology (ESC) guidelines [17]. ...
Article
Full-text available
Identification of ischemia remains critical when assessing individuals presenting with atypical symptoms or in patients with known coronary artery disease (CAD). Several imaging modalities are currently available to attain this diagnostic goal. Unfortunately, not all case presentations are straightforward, particularly when microvascular dysfunction (MVD) is the cause of symptoms in the absence of identifiable epicardial luminal stenosis. Specifically, in such cases, current imaging guidelines do not include stress echocardiography (SE) as a recommended tool when assessing these patients. We present three cases that highlight the utility of SE for identifying MVD and provide mechanistic explanations. We believe that SE should not be completely discarded as an inadequate testing modality; we highlight the potential utility of this imaging modality not only in diagnosing CAD and pre-surgical evaluation of patients but also in identifying patients with MVD.
Chapter
Provocative cardiac testing has had an important role in recent advances in the management of low-risk patients presenting to the emergency department (ED) with chest pain (CP). These patients comprise a majority of those presenting to the ED with CP, and provocative cardiac testing is one of the approaches that has facilitated safe, rapid, and cost-effective evaluation of these patients. The major methods for provocative testing in this setting are treadmill exercise (ETT), stress echocardiography (SE), and myocardial perfusion imaging (MPI). Cardiac magnetic resonance has also had limited application in low-risk patients presenting with CP. In addition to cardiac provocation by exercise, pharmacologic agents can be utilized for this purpose in all of the imaging techniques noted above. Although these methods differ in methodology, applicability, limitations, adverse effects, and sensitivity and specificity for detection of coronary artery disease and myocardial ischemia, they all have very high negative predictive values for excluding a coronary event in low-risk patients presenting with CP. This factor, in association with a low-risk clinical evaluation, has promoted the development of accelerated diagnostic protocols which have enabled early discharge of the low-risk patient.KeywordsAcute chest painAcute coronary syndromeCardiac stress testingMyocardial stress imagingMyocardial stress perfusionCardiac MRIRisk scoreshs-cardiac troponinObservation units
Article
Aim This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. Methods A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. Structure Chest pain is a frequent cause for emergency department visits in the United States. The “2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain” provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
Article
Aim: This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. Methods: A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. Structure: Chest pain is a frequent cause for emergency department visits in the United States. The "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain" provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
Article
Aim This executive summary of the clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. Methods A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. Structure Chest pain is a frequent cause for emergency department visits in the United States. The “2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain” provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. These guidelines present an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated and shared decision-making with patients is recommended.
Article
Aim This clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. Methods A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing randomized and nonrandomized trials, observational studies, registries, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. Structure Chest pain is a frequent cause for emergency department visits in the United States. The “2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain” provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. This guideline presents an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated, and shared decision-making with patients is recommended.
Article
Aim This executive summary of the clinical practice guideline for the evaluation and diagnosis of chest pain provides recommendations and algorithms for clinicians to assess and diagnose chest pain in adult patients. Methods A comprehensive literature search was conducted from November 11, 2017, to May 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Collaboration, Agency for Healthcare Research and Quality reports, and other relevant databases. Additional relevant studies, published through April 2021, were also considered. Structure Chest pain is a frequent cause for emergency department visits in the United States. The “2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain” provides recommendations based on contemporary evidence on the assessment and evaluation of chest pain. These guidelines present an evidence-based approach to risk stratification and the diagnostic workup for the evaluation of chest pain. Cost-value considerations in diagnostic testing have been incorporated and shared decision-making with patients is recommended.
Chapter
Chest pain is among the most common causes of emergency room (ER) visits, making its diagnosis a challenging one. The causes of this symptom range from musculoskeletal causes to potentially life-threatening emergencies, such as coronary artery disease. The fact that its presentation is subjective makes it difficult for the clinician to assess it; wherefore, good clinical evaluation is mandatory. Most patients presenting with classical chest pain and accompanying symptoms are easily diagnostic-oriented; however, there are an important fraction of patients that will not present with typical symptomatology. This observation indicates that the diagnostic workup for chest pain needs to be a very thorough one and additionally a very time-effective one; that is why having specific guidelines for chest pain can be lifesaving. It is essential to accurately risk stratify these patients to improve ER efficiency and avoid unnecessary tests and admissions. For this, risk scores are very useful to give a more objective view and stratify our patient and guide the next steps to take. The use of imaging techniques as a first approach to chest pain has been something in constant evolution, but still in research, especially the use of the immediate exercise stress echocardiogram, which greatly reduces the time for diagnosis, compared to a full clinical workup. It is of remark that this is an introduction to chest pain and its most common causes; for the specific treatment for each suspected pathology, we refer to the next chapters in this book.
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