The challenge of optimal evaluation of low and intermediate pretest probability stable chest pain: Insights from recent randomized clinical trials

Abstract

Given the wide knowledge gaps in the evaluation of patients with low and intermediate pretest probability stable chest pain and the ubiquity of noninvasive imaging the below mentioned largest, most comprehensive and timely randomized clinical trials (RCTs), provide valuable insights into risk stratification, diagnosis, management, prognostication, and outcomes. Rapid clinical assessment of patients with low/intermediate-risk stable chest pain can identify high-risk individuals. However, about 33% of patients labeled as noncardiac chest pain die from cardiovascular disease or develop acute coronary syndrome (ACS) during 5 years follow-up. About 1.5% of patients with ACS are missed even after extensive testing leading to potential medical, legal, and psychological sequelae. As a result, clinicians have a low threshold to admit even low risk patients for prolonged expensive observation and testing leading to unnecessary admissions, false-positive test results, and unnecessary invasive downstream investigations. This scenario gives a clarion call for improving the diagnostic accuracy, risk stratification, and prognostication in low/intermediate-risk stable chest pain patients. The most common clinical scenario most of us come across is a middle-aged patient with new onset/recurrent low/intermediate-risk stable chest pain attending the emergency department (ED). Issues which are head scratching and mindboggling about this scenario is the ability of the clinician to optimally utilize the appropriate tests from the available armamentarium of functional, anatomical and biochemical diagnostic strategies (exercise electrocardiogram, stress echocardiogram, nuclear stress test, computed tomographic coronary angiography, and circulating biomarkers) to arrive at accurate diagnosis for flawless management. One of the main purposes of the article is to avoid underdiagnosis, overdiagnosis, and misdiagnosis in patients with stable chest pain. We have cherry-picked four large recent landmark RCTs to help the clinician to sharpen his clinical skills, maximize diagnostic accuracy, speed up emergent interventions, assist in surgical planning, and optimize medical therapies. Unfortunately, physical examination for determining the cause of low/intermediate-risk stable chest pain is neither sensitive nor specific to identify obstructive coronary artery disease (CAD). The four recent RCTs are as follows: (1) PROspective Multicenter Imaging Study for Evaluation of Chest Pain trial; (2) Scottish COmputed Tomography of the History, Electrocardiogram, Age, Risk factors, and initial Troponin Trial; (3) Impact on Management of the HEART Risk Score in Chest Pain Patients trial; and (4) Randomized Investigation of Chest Pain Diagnostic Strategies, Shared Decision-Making in the ED: Chest Pain Choice trial.