Coronary Disease in Emergency Department Chest Pain Patients with Recent Negative Stress Testing

BACKGROUND: Cardiac stress tests for diagnosis of coronary artery disease (CAD) are incompletely sensitive and specific. OBJECTIVE: We examined the frequency of significant CAD in patients presenting to the emergency department (ED) with chest pain who have had a recent negative or inconclusive (<85% of predicted maximum heart rate) cardiac stress test. METHODS: This was a retrospective chart review of patients identified from ED and cardiology registries at the study hospital. We included patients presenting to the ED with a chief complaint of chest pain, with a negative cardiac stress test in the past three years as the last cardiac test, and hospital admission. One-hundred sixty-four patients met the inclusion criteria. Their admission was reviewed for diagnosis of CAD by positive serum troponin, percutaneous coronary intervention, or positive stress test while an inpatient. RESULTS: Of 164 patients, 122(74.4%, 95% CI 67.7, 81.1) had a negative stress test prior to the index admission, while 42 (25.6%, 95% CI 18.9, 32.3) had otherwise normal but inconclusive stress tests. Thirty-four (20.7%, 95% CI 14.4,27.0) of the included patients were determined to have CAD. Twenty-five of the 122 patients (20.5%, 95% CI 13.3, 27.7) had negative pre-admission stress tests and nine of 42 patients (21.4%, 95% CI 9.0, 33.8) had inclusive stress tests of CAD. A statistical comparison between these two proportions showed no significant difference (p = .973). CONCLUSION: Due to inadequate sensitivity, negative non-invasive cardiac stress tests should not be used to rule out CAD. Patients with negative stress tests are just as likely to have CAD as patients with inconclusive stress tests.