Stress myocardial perfusion imaging for the evaluation and triage of chest pain in the emergency department: A randomized controlled trial
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Patients with acute coronary syndrome (ACS) often present atypically. In a randomized controlled trial, we studied whether adding stress myocardial perfusion imaging (SMPI) to an evaluation strategy for emergency department (ED) patients presenting with chest pain more effectively identifies patients with ACS.
Participants were randomized to standard ED chest pain protocol (clinical assessment) or standard protocol supplemented with SMPI results. During 6 hours of electrocardiogram (ECG) monitoring and serial cardiac markers (creatine kinase-MB isoenzyme, troponin), participants developing ST segment changes or elevated cardiac markers were admitted. Those with a negative observation period underwent SMPI (N = 1,004) or clinical assessment (N = 504) based on randomization, and admitted if their SMPI scan was abnormal or senior clinicians found a high or intermediate risk for ACS.
SMPI participants had a significantly lower admission rate than clinical assessment participants (10.16% vs 18.45%), with no significant between-group differences in risk of cardiac events (CEs) after 30 days (0.40% vs 0.79%) or 1 year (0.70% vs 0.99%).
When added to a standard triage strategy incorporating clinical evaluation, serial ECGs, and cardiac markers, SMPI improved clinical decision making for chest pain patients, significantly reducing the need for hospitalization without an increase in adverse CE rates at 30 days or 1 year.
KeywordsCardiac event acute coronary syndrome acute chest pain cardiac troponin risk stratification emergency department
This study was supported by grants from the National Medical Research Council, Ministry of Health, Singapore [Grant Numbers NMRC/0517/2001]. We acknowledge the assistance and efforts of the doctors, nurses, and staff from the Department of Emergency Medicine, Department of Nuclear Medicine and Division of Biochemistry at Singapore General Hospital, and the Department of Cardiology at the National Heart Centre Singapore. We acknowledge Ms. Kelly Wong, Ms. Evelyn Tan, Ms. Cheong Xiu Hui Priscilla, Ms. Tang Ling Hui, Dr Thander Aye, Dr Nilar Hla, and Dr Thein Htay Oo who were instrumental in ensuring that data capture was complete, and Dr Tan Tiong Peng, Dr Fong Yuke Tien, and Dr Rabind Charles for overseeing the conduct of the stress testing. The authors appreciate the support of the editorial assistance provided by Jon Kilner, MS, MA (Pittsburgh, PA, USA), who was funded through the Singapore Clinical Research Institute, Ministry of Health Holdings.
Conflict of interest
The authors declare that they have no conflict of interest.
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