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Does everyone with chest pain need a stress test?

NEW YORK (Reuters Health) – People who come to the emergency department complaining of chest pain often get stress tests that aren’t helping them very much, according to a new study.

The results “showed something that we have thought, that we probably do stress testing too often,” said Dr. Troy Madsen, a professor at the University of Utah School of Medicine, who was not involved in the research.

Dr. Srikanth Penumetsa and colleagues of Baystate Medical Center in Springfield, Massachusetts, who published their findings online May 7th in the Archives of Internal Medicine, sought to find out whether giving stress tests to people admitted to the hospital with chest pain was helping to identify those who would end up having a heart attack within the month following the hospital visit.

They looked back on the medical records of about 2,100 patients who had been admitted over a two-year period to their hospital.

Seven out of every 10 patients received a stress test, with abnormal results in 12%.

Of the 184 patients who had abnormal results, 23 (12.5%) underwent a follow-up test (usually angiography) and 10 had bypass surgery or stenting.

Dr. Madsen said he was surprised that more people didn’t get a follow up test – but Dr. Penumetsa said not all patients require an angiogram after an abnormal test, and “therefore I do not think this number should have been higher.”

Within a month after discharge, seven patients suffered a heart attack, including three who had undergone stress testing.

Dr. Penumetsa said the results show that stress testing does not lower the chances of having a heart attack within the next 30 days.

“Since stress testing has not been shown to decrease the risk of having a heart attack, there is no absolute need to routinely perform this test prior to discharge,” Dr. Penumetsa wrote in an email to Reuters Health.

Dr. Anthony Napoli, an emergency physician at Rhode Island Hospital, said a good starting place to reduce unnecessary stress tests would be with patients at low risk of having heart disease.

“They might be the one group that you could target as having a planned protocol that would say, those who are low risk don’t get a stress test and just get a certain follow up,” Dr. Napoli said. “That would reduce stress test utilization, but also maintain the same safety and efficacy.”

Dr. Penumetsa suggested that after a brief observation in the hospital, and after a heart attack is ruled out, patients could be sent home and followed up a few days later in a doctor’s office, instead of given a stress test.

Dr. Napoli, who was not involved with the new research, said the idea of limiting stress tests to those at a higher risk of having a heart attack would need to be studied before it could be widely recommended.

Dr. Penumetsa also that doctors’ concerns over lawsuits might also be affecting their care.

“If they’ve ordered a stress test, then they can say that ‘they’ve done everything possible’ before sending the patient home, even if ‘everything possible’ doesn’t actually change the outcome at all,” said Dr. Penumetsa.


Arch Intern Med 2012.