Contemporary Risk Stratification of Chest pain and its Implications in the Era of Advanced Cardiac Imaging
By Joseph Yeboah,
MD, MS, FACC, FAHA
Department of cardiovascular Medicine, Wake Forest Baptist Health, Winston Salem NC
Current society guidelines recommends stress testing for individuals deemed intermediate risk by healthcare professionals after a careful history, physical examination and preliminary testing. Stress testing often includes a cardiac imaging component and with current advancement, there are thankfully quite a few to choose from depending on patients characteristics. However, current data shows that even in carefully selected appropriate patients with chest pains, a stress test as a screening tool is not ideal. At best , with a cut off of >50% coronary stenosis on angiography for patient with a positive stress tests, the sensitivity and specificity of a stress test is a little over 80%. With current clinically significant threshold for coronary stenting at >70% and the improvement in cardiac imaging techniques, the sensitivity of a positive stress test is bound to be higher but at the cost of a significantly reduced specificity( high false positive rate).
The current paradigm of assessing patients with chest pains, i.e. speed/fast throughput in our emergency rooms, ability of ancillary stuff with less training to order the test, defensive medicine practice and patient expectations has led to inadequate selection process for chest pain patients and hence overuse of these costly cardiac imaging techniques with significant consequences. The history/physical exam/preliminary test has been replaced with scores, some of which has very poor clinical utility. In some scenarios, the mention of chest pain alone buys a patient a stress test even though most of these chest pains are non-cardiac pain in low risk individuals. The poor patient selection has amplified the false positive rate of stress testing and has increase exposure of patient to unnecessary invasive testing and cost. In their effort to control cost, there has been an astronomical increase in “peer to peer” justifications for stress testing even in patient deem appropriate for the test according to current guidelines, adding another layer of bureaucracy to the practice of medicine. The irony is that the insurance company’s representative on the other side of the “peer to peer” call is often a non-medic with a list in front of him/her listening for keywords or phrases to either deny or approve the stress test.
Cardiovascular disease is the leading cause of death in the western world and chest pain is the most common symptom. With the aging population and advancement in cardiac imaging, we are bound to see more patients with chest pain and would have more cardiac imaging tools to risk stratify them. The status quo of chest pain evaluation will only increase the inappropriate use of advance cardiac imaging and erect more barriers in their application in patient care. This will ultimately limit the clinical utilization and subsequently research in advance cardiac imaging modalities.
Chest pain evaluation will only increase the inappropriate use of advance cardiac imaging and erect more barriers in their application in patient care.
Joseph Yeboah,MD, MS, FACC, FAHA