UMEM Educational Pearls

Title: Recent Negative Stress Tests in Chest Pain Bouncebacks

Keywords: ACS, Stress Test (PubMed Search)

Posted: 2/23/2014 by Ali Farzad, MD (Updated: 3/23/2014)
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Over-reliance on stress tests is a common reason for misdiagnosis or delays in diagnosis in patients with ACS.

The utility of a recent negative stress test is limited when it is used to determine the risk for an ACS in patients presenting to the emergency department with symptoms of cardiac ischemia.

Several studies, including a meta analysis, show that while a positive stress test can be useful in determining the next appropriate step of a patient's care, a negative stress test may not be as useful.

ED patients who bounceback after a negative stress test, represent a much higher risk population that may be at the same risk for ACS as those without previous testing.

Bottom Line:

No test is capable of reliably stratifying a patient’s risk to zero. If you are concerned about an ED chest pain patient with a HPI suggestive of ACS, treat conservatively and do not be misled by a recent negative stress test.

Bonus:

Working in an observation unit and don't know what stress test to order? Check out Dr. Mattu's lecture Non-invasive cardiac stress testing: What every emergency physician needs to know (Need EmedHome subscription for link to work).

References

1. Banerjee A, Newman DR, Van den Bruel A, Heneghan C. Diagnostic accuracy of exercise stress testing for coronary artery disease: a systematic review and meta-analysis of prospective studies. International Journal of Clinical Practice. 2012;66(5):477–492.

2. Walker J, Galuska M, Vega D. Coronary disease in emergency department chest pain patients with recent negative stress testing. West J Emerg Med. 2010;11(4):384–388.

3. Nerenberg RH, Shofer FS, Robey JL, Brown AM, Hollander JE. Impact of a negative prior stress test on emergency physician disposition decision in ED patients with chest pain syndromes. The American journal of emergency medicine. 2007;25(1):39–44.

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