Abstract
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.
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References
Amsterdam EA, Kirk JD, Bluemke DA, Diercks D, Farkouh ME, Garvey JL, Kontos MC, McCord J, Miller TD, Morise A, Newby LK, Ruberg FL, Scordo KA, Thompson PD. Testing of low-risk patients presenting to the emergency department with chest pain: a scientific statement from the American Heart Association. Circulation. 2010;122:1756–76.
Amsterdam EA, Kirk JD, Diercks DB, Lewis WR, Turnipseed SD. Immediate exercise testing to evaluate low-risk patients presenting to the emergency department with chest pain. J Am Coll Cardiol. 2002;40:251–6.
Stauber SM, Teleten A, Li Z, Venugopal S, Amsterdam EA. Prognosis of low-risk young women presenting to the emergency department with chest pain. Am J Cardiol. 2015;117:36–9.
Prasad P, Sharma A, Vipparla N, Majid M, Daniela A, Howell S, Wilson M, Amsterdam EA. Identification and management of intermediate risk patients in the chest pain unit. Crit Pathw Cardiol. 2019;19:26–9.
Eddin M, Venugopal S, Chatterton B, Thinda A, Amsterdam EA. Long-term prognosis of low-risk women presenting to the emergency department with chest pain. Am J Med. 2017;130:313–7.
Howell SJ, Bui JB, Balasingam T, Amsterdam EA. Utility of Physician Selection of Cardiac Tests in a Chest Pain Unit to Exclude Acute Coronary Syndrome Among Patients Without a History of Coronary Artery Disease. Am J Cardiol. 2018;121:825–9.
Howell SJ, Prasad P, Vipparla NS, Venugopal S, Amsterdam EA. Usefulness of predischarge cardiac testing in low risk women and men for safe, rapid discharge from a chest pain unit. Am J Cardiol. 2019;123:1772–5.
Amsterdam EA, Takahashi N, Majid M, Taha S, Alismail Y, Venugopal S. Chapter “Exercise electrocardiographic stress testing”. In: Wong N, Amsterdam EA, Toth PP, editors. ASPC manual of preventive cardiology. 2nd ed. New York, NY: Humana Press; 2020.
Chaitman BR. Exercise electrocardiographic stress testing. In: Beller GA, editor. Chronic ischemic heart disease. In Braunwald E (series ed), Atlas of heart diseases. Vol 5. Chronic Ischemic Heart Disease. Philadelphia, Current Medicine; 1995. p. 2.1–2.30.
Takahashi N, Gall E, Fan D, Majid M, Amsterdam EA. ST elevation during recovery phase of exercise test. Am J Med. 2020;133:1287–90.
Beri N, Dang P, Bhat A, Venugopal S, Amsterdam EA. Usefulness of excellent functional capacity in men and women with ischemic exercise electrocardiography to predict a negative stress imaging test and very low late mortality. Am J Cardiol. 2019;124:661–5.
Farkouh M, Smars PA, Reeder GS, Zinsmeister AR, Evans RW, Meloy TD, Kopecky SL, Allison TG, Gibbons RJ, Gabriel SE. A clinical trial of a chest-pain observation unit for patients with unstable angina. NEJM. 1998;339:1882–8.
Gomez MA, Anderson JL, Labros AK, Muhlestein JB, Mooders FB. An emergency department-based protocol for rapidly ruling out myocardial ischemia reduces hospital time and expense: results of a randomized study (ROMIO). J Am Coll Cardiol. 1996;28:25–33.
Amsterdam EA, Aman E. The patient with chest pain. Low risk, high stakes. JAMA Intern Med. 2014;174:553–4.
Winchester DE, Brandt J, Schmidt C, Allen B, Payton T, Amsterdam EA. Diagnostic yield of routine noninvasive cardiovascular testing in low-risk acute chest pain patients. Am J Cardiol. 2015;116:204–7.
Amsterdam EA, Venugopal S. Utility of simplicity for low-risk chest pain patients. Eur Heart J Acute Cardiovasc Care. 2018;7:285–6.
Booth J, Thomas JJ. Provocative testing for low-risk chest pain patients, must we continue? J Nucl Cardiol. 2019;26:1647–9.
Trippi JA, Lee KS, Kopp G, Nelson DR, King GY, Cordel WH. Dobutamine stress tele- echocardiography for evaluation of emergency department patients with chest pain. J Am Coll Cardiol. 1997;30:627–32.
Trippi JA, Lee KS. Dobutamine stress tele-echocardiography as a clinical service in the emergency department to evaluate patients with chest pain. Echocardiography. 1999;16:179–85.
Davies R, Liu G, Sciamanna C, Davidson WR Jr, Leslie DL, Foy AJ. Comparison of the effectiveness of stress echocardiography versus myocardial perfusion imaging in patients presenting to the emergency department with low-risk chest pain. Am J Cardiol. 2016;118:786–1791.
Levsky JM, Haramati LB, Spevack DM, Menegus MA, Chen T, Mizrachi S, Brown-Manhertz D, Selesny S, Lerer R, White DJ, Tobin JN, Taub CC, Garcia MJ. Coronary computed tomography angiography versus stress echocardiography in acute chest pain: a randomized controlled trial. JACC Cardiovasc Imaging. 2018;11:1288–97.
Jasani G, Papas M, Patel AJ, Jasani N, Levine B, Zhang Y, Marshall ES. Immediate stress echocardiography for low-risk chest pain patients in the emergency department: a prospective observational cohort study. J Emerg Med. 2018;54:156–64.
Samiei N, Parsaee M, Pourafkari L, Tajlil A, Pasbani Y, Rafati A, Nader ND. Value of negative stress echocardiography in predicting cardiovascular events among adults with no known coronary disease. J Cardiovasc Thorac Res. 2019;11:85–94.
Lewis WR, Arsna FJ, Galloway MT, Bommer WJ. Acute myocardial infarction associated with dobutamine stress echocardiography. J Am Soc Echocardiogr. 1997;10:576–8.
Henzlova MJ, Duvall WL, Einstein AJ, Travin MI, Verberne HJ. ASNC imaging guidelines for SPECT nuclear cardiology procedures: stress, protocols, and tracers. J Nucl Cardiol. 2016;23:606–39.
Udelson JE, Beshansky JR, Ballin DS, Feldman JA, Griffith JL, Handler J, Heller GV, Hendel RC, Pope JH, Ruthazer R, Spiegler EJ, Woolard RH, Selker HP. Myocardial perfusion imaging for evaluation and triage of patients with suspected acute cardiac ischemia: a randomized controlled trial. JAMA. 2002;288:2693–7000.
Nabi F, Kassi M, Muhyieddeen K, Chang SM, Xu J, Peterson L, Wray N, Shirkey B, Ashton C, Mahmarian J. Optimizing evaluation of patients with low-to-intermediate-risk acute chest pain: a randomized study comparing stress myocardial perfusion tomography incorporating stress-only imaging versus cardiac CT. J Nucl Med. 2016;2016(57):378–84.
Rybicki FJ, Udelson JE, Peacock WF, Goldhaber SZ, Isselbacher EM, Kazerooni E, Kontos MC, Litt H, Woodard PK, Emergency Department Patients With Chest Pain Rating Panel; Appropriate Utilization of Cardiovascular Imaging Oversight Committee. ACR/ACC/AHA/AATS/ACEP/ASNC/NASCI/SAEM/SCCT/SCMR/SCPC/SNMMI/STR/STS. J Am Coll Cardiol. 2016;67:853–9.
Amirian J, Javdan O, Misher J, et al. Comparative efficiency of exercise stress testing with and without stress-only myocardial perfusion imaging in patients with low-risk chest pain. J Nucl Cardiol. 2018;25:1274–82.
Ingkanisorn PW, Kwong RW, Bohme NS, Geller NL, Rhoads KL, Dyke CK, Paterson DI, Mushabbar AS, Aletras AH, Arai AE. Prognosis of negative adenosine stress magnetic resonance in patients presenting to an emergency department with chest pain. J Am Coll Cardiol. 2006;47:1427–32.
Lerakis S, McLean DS, Anadiotis AV, Janik M, Oshinski JN, Alexopoulos N, Zaragoza-Macias E, Veledar E, Stillman AE. Prognostic value of adenosine stress cardiovascular magnetic resonance in patients with low-risk chest pain. J Cardiovasc Magn Reson. 2009;11:37.
Heitner JF, Klem I, Rasheed D, Chandra A, Kim HW, Van Assche LM, Parker M, Judd RM, Jollis JG, Kim RJ. Stress cardiac MR imaging compared with stress echocardiography in the early evaluation of patients who present to the emergency department with intermediate-risk chest pain. Radiology. 2014;271:56–64.
Balfour PC Jr, Gonzalez JA, Kramer CM. Non-invasive assessment of low- and intermediate-risk patients with chest pain. Trends Cardiovasc Med. 2017;27:182–9.
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Amsterdam, E.A., Venugopal, S., Majid, M., Aman, E. (2022). Provocative Testing. In: Pena, M., Osborne, A., Peacock, W.F. (eds) Short Stay Management of Chest Pain. Contemporary Cardiology. Humana, Cham. https://doi.org/10.1007/978-3-031-05520-1_14
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