Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health

Introduction: Chest pain (CP) patients in the Emergency Department (ED) present a diagnostic dilemma, with a low prevalence of coronary disease but grave consequences with misdiagnosis. A common diagnostic strategy involves ED cardiac monitoring while excluding myocardial necrosis, followed by stress testing. We sought to describe the use of stress echocardiography (echo) at our institution, to identify cardiac pathology compared with stress electrocardiography (ECG) alone.

Methods: Retrospective cohort study of 57 urban ED Chest Pain Unit (CPU) patients from 2002-2005 with stress testing suggesting ischemia. Our main descriptive outcome was proportion and type of discordant findings between stress ECG testing and stress echo. The secondary outcome was whether stress echo results appeared to change management.

Results: Thirty-four of 57 patients [59.7%, 95% confidence interval (CI) 46.9-72.4%] had stress echo results discordant with stress ECG results. The most common discordance was an abnormal stress ECG with a normal stress echo (n=17/57, 29.8%, CI 17.9-41.7%), followed by normal stress ECG but with reversible regional wall-motion abnormality on stress echo (n = 10/57, 17.5%, CI 7.7-27.4%). The remaining seven patients (12.3%, CI 3.8-20.8%) had non-diagnostic stress ECG due to sub-maximal effort. Stress echo showed reversible wall-motion abnormality in two, and five were normal. Twenty-five of the 34 patients (73.5%, CI 56.8-85.4%) with discordant results had a different diagnostic strategy than predicted from their stress ECG alone.

Conclusion: The addition of echo to stress ECG testing in ED CPU patients altered diagnosis in 34/57 (59.7%, CI 46.9-72.4%) patients, and appeared to change management in 25/57 (43.9%, CI 31.8-57.6%) patients. [West J Emerg Med. 2010; 11(4):379-383.]