In This Edition
Literature at a Glance
A guide to this month’s studies
- Stress testing in young patients with chest pain.
- Family presence during CPR.
- Achieving rate control in rapid atrial fibrillation.
- D-dimer in aortic dissection.
- Acute kidney injury outcomes.
- Statins after stroke.
- Low-dose steroids in septic shock.
- Genetic testing for VTE.
1) Utility of Cardiac Stress Testing Is Limited for Young Patients with Chest Pain
Clinical question: Does routine, provocative cardiac testing in low-risk adult patients younger than 40 years of age add to the diagnostic evaluation for acute coronary syndrome?
Background: In EDs, aggressive evaluation of chest pain is the standard of care due to high morbidity, mortality, and liability associated with acute coronary syndrome (ACS). Guidelines recommend provocative cardiac testing for all patients for whom ACS is suspected, yet the prevalence is low in patients younger than 40.
Study design: Retrospective observational study.
Setting: ED chest pain observation unit of an urban academic tertiary-care center in New York City.
Synopsis: Two hundred twenty patients between 22 and 39 years old admitted for ACS evaluation between March 2004 and September 2007 were eligible. Patients with known coronary artery disease, diagnostic ECG ﬁndings, or evidence of cocaine use were excluded. Provocative cardiac testing for the presence of myocardial ischemia followed serial cardiac biomarker testing to rule out myocardial infarction.
Six patients had positive stress tests. Four underwent subsequent coronary angiography, which demonstrated no evidence of obstructive coronary disease. One refused catheterization, and the other was lost to followup. Age younger than 40 years, nondiagnostic or normal ECG, and two sets of negative cardiac biomarker results at least six hours apart identified a patient group with a low rate of true-positive provocative testing.
This study is limited by its retrospective, single-centered nature; it was unable to include patients admitted to the hospital or those who left the chest-pain unit without provocative testing or against medical advice. The possibility of false-negative provocative testing results was not excluded. The methods of provocative testing were limited to those available prior to 2007.