Ayub, Bilal, MD

Nawaz, Yassir, MD

English

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health NetworkLVHN Scholarly WorksDepartment of MedicineA Retrospective Chart Review to DetermineProper Stress Test Utilization in Low Risk ChestPain PatientsYassir Nawaz MDLehigh Valley Health Network, Yassir.Nawaz@lvhn.orgBilal Ayub MDLehigh Valley Health Network, Bilal.Ayub@lvhn.orgFollow this and additional works at: http://scholarlyworks.lvhn.org/medicinePart of the Analytical, Diagnostic and Therapeutic Techniques and Equipment Commons,Cardiovascular Diseases Commons, and the Medical Sciences CommonsThis Poster is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by anauthorized administrator. For more information, please contact LibraryServices@lvhn.org.Published In/Presented AtNawaz, V. & Ayub, B. (2014, June, 22). A Retrospective Chart Review to Determine Proper Stress Test Utilization in Low Risk Chest PainPatients. Poster presented at the Complex Cardiovascular Catheter Therapeutics, Orlando, FL.Lehigh Valley Health Network, Allentown, PennsylvaniaYassir Nawaz MD, Bilal Ayub MDIntroduction•		Patient presenting with chest pain to the ED is a very common clinical problem.•		This is the second most common presentation to the emergency departments. •		A typical chest pain admission requires serial EKGs, cardiac biomarkers, stress testing, echocardiography and if needed invasive testing such as cardiac catheterization.•		The extent of workup depends upon clinical history, physical examination, risk factors, and initial workup ( EKGs and cardiac enzymes).•		There are many scoring criteria such as TIMI risk score, simple risk scoring and Grace score that help to risk stratify chest pain patients and to determine the appropriate workup. A Retrospective Chart Review to Determine Proper Stress Test Utilization in Low Risk Chest Pain Patients References:1	 	Amsterdam	EA,	Kirk	JD,	Bluemke	DA	et	al.Testing	of	low-risk	patients	presenting	to	the	emergency	department	with	chest	pain:	a	scientific	statement	from	the	American	Heart	Association.Circulation.	2010	Oct	26;122(17):1756-76.	Epub	2010	Jul	26.2	 	Lee	TH,	Goldman	L.	Evaluation	of	the	patient	with	acute	chest	pain.	N	Engl	J	Med.	2000;342:1187–1195.	3	 	Antman	EM,	Cohen	M,	Bernink	PJ,	McCabe	CH,	et	al.	The	TIMI	risk	score	for	unstable	angina/non-ST	elevation	MI:	A	method	for	prognostication	and	therapeutic	decision	making.	JAMA.	2000	Aug	16;284(7):835-42.4	 	Gomez	MA,	Anderson	JL,	Karagounis	LA,	Muhlestein	JB,	Mooers	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.© 2014 Lehigh Valley Health NetworkMethods•		It was a retrospective observational chart review and included patients that were admitted with a primary diagnosis of chest pain.•		Patients were included if they had atypical chest pain with no prior history of coronary artery disease (CAD) and a normal initial EKG and first troponin.•		Patient were excluded if they have typical chest pain, or a history of CAD,  an abnormal admission EKG or positive cardiac enzymes. •		All included patients underwent further risk stratification per TIMI Risk score from 0 to a maximum score of 4. (Since history of CAD, abnormal EKG and positive Biomarkers were already excluded the maximum calculated TIMI risk of this population was 4).•		Stress test utilization in each TIMI risk class was determined. •		Patients were divided into stressed and non stressed groups.•		Cardiac outcomes such as acute coronary syndrome, Death, 30 day re-hospitalizations due to cardiac events were compared between the two groups. Results•		164 consecutive low risk chest pain patients were included based on the inclusion criteria. •		Patients were stratified by TIMI risk score from 0 to a maximum score of 4 (Figure 1). •		A stress test was performed in 48% of the patients.•		Patient’s with higher TIMI scores did not have more stress test ordered and there was no association between TIMI risk scores and utilization of the stress test (p = 0.494) (Figure 2). •		None of the stress tests were true positive.   •		There were no acute coronary syndromes, deaths or 30 day re-hospitalizations due to cardiac events in these patients whether they did or did not have an inpatient stress test.Conclusions•		In low risk populations stress test is low yield.  •		Stress testing was over utilized independent of patient’s risk. •		A proportional increase in stress test utilization compared to risk was not seen. •		A proper risk stratification on admission can decrease stress test utilization for very low risk patients TIMI scores 0-2. Disclosures:   None.ObjectivesThe objectives of this study were to:•		Examine the utilization of inpatient stress tests in low risk chest pain admissions.•		To determine if proper risk stratification is utilized at admission to order stress tests.•		To determine the incidence of outcomes such as acute coronary syndromes, MI, Death, 30 day re-hospitalization in low risk chest pain admissions?0 0 0 0 000.10.20.30.40.50.60.70.80.91TIMI 0 TIMI 1 TIMI 2 TIMI 3 TIMI 4Number ofPatients inEach TIMIClass26534431100 0 0 0 000.10.20.30.40.50.60.70.80.91TIMI 0 TIMI 1 TIMI 2 TIMI 3 TIMI 4% ofPatientsStressedNo associationP = 0.494 (Chi Square)Figure 2533750 5260Table 1. TIMI Risk Score Historical PointsAge > 65 Y 1> 3 CAD risk factors (FH, HTN, ↑ chol, DM active smoker) 1Known CAD (stenosis > 50%) 1ASA use in past 7 days 1PresentationRecent (> 24h) severe angina 1↑ cardiac markers 1ST deviation > 0.05 mV 1RISK SCORE - Total Points (0-7)   Table 3. Cardiac Outcomes Stressed Not StressedAcute Coronary Syndromes 0 0Death 0 030 Day Re-hospitalization due to Cardiac Reasons 0 0   Table 2. Population Characteristics Frequency Percent of TotalFemale Sex 55 66.5%Hypertension 104 63%Diabetes Mellitus 38 23%Current Smoker 32 20%Hyperlipidemia 80 49%Family History of CAD 62 38%Stress Test Performed 78 48%   Figure 1TIMI Risk DistributionFigure 2Stress Test Utilization Per TIMI RiskStudy SubjectsExcluded Patients: 108History of CAD - 82Elevated 1st Troponin - 6EKG changes - 6Typical Chest Pain - 5Wrong Diagnosis - 9 (PE: 5, PNA: 3, UTI: 1)Low Risk ChestPain Patients164Stressed78Not Stressed86Total Patients272

A Retrospective Chart Review to Determine Proper Stress Test Utilization in Low Risk Chest Pain Patients

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A Retrospective Chart Review to Determine Proper Stress Test Utilization in Low Risk Chest Pain Patients

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