NEW YORK (Reuters Health) – Patients with a textbook case of “typical” angina are no more likely than patients with atypical or nonanginal chest pain to have inducible myocardial ischemia on stress testing, researchers from New York’s Mount Sinai Medical Center report.
“Accurate risk stratification in the potential acute coronary syndrome (ACS) patient is not as simple as combining age, gender, and presenting symptom,” lead author Dr. Luke K. Hermann told Reuters Health by email.
“Common teaching is that if we as physicians ask the right questions, we will be rewarded with the correct diagnosis,” he said. “Unfortunately, the clinical reality is rarely so clear. This points to the need for improved risk stratification tools, an issue that will become ever more important as we attempt to limit unnecessary testing to control spiraling health care costs.”
Using stress test data from 2525 emergency department patients, Dr. Hermann and his colleagues analyzed rates of inducible myocardial ischemia in patients who presented with typical anginal pain, atypical/nonanginal pain, or no chest pain at all.
They reported online April 12th in the American Journal of Cardiology that 296 patients (11.7%) had positive stress tests – including 33 of 231 (14%) with typical anginal pain, 238 of 2294 (10%) with atypical/nonanginal symptoms, and 25 of 153 (16%) without chest pain.
There was no significant difference in the likelihood of having inducible myocardial ischemia among these groups, the researchers said.
Presentation did not vary significantly by gender, age, or diabetes status.
“These results contradict those from previous studies of non-emergency department patients and challenge the conventional wisdom that patients with a greater likelihood of obstructive coronary artery disease can be identified on the basis of their symptoms alone,” the investigators say.
“Until alternatives are identified, however, we have little but our own gestalt based on presenting symptoms and underlying risk factors to help us decide who warrants testing,” Dr. Hermann said. “Not that it should factor prominently, but I doubt the legal and insurance communities are likely to let go of the perceived value of a presenting symptom for determining who warrants further work-up, which in turn will have obvious impact on actual practice.”
Am J Cardiol 2010.