STRESS (Stress Test Relevance and Education Self Study

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STRESS (Stress Test Relevance and Education Self
Study)
Robert Post, M.D. Caisson Hogue, M.D. Stephen
Thomas, M.D.
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Background

• The Trident/MUSC Family Medicine Residency
  Program (FMRP) admits many patients (10-15) with
  a chief complaint of chest pain.  
• Although some patients have findings of ACS, the
  majority have negative cardiac enzymes and normal
  EKG findings.

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Background

• Prior to discharge of these patients, the team
  often asks Does this patient need a stress
  test? to aid in a diagnosis of coronary artery
  disease (CAD).
• Among various studies, the prevalence of CAD in
  patients who present to an ER with chest pain is
  5-25
• In 2002, the American College of Cardiology
  (ACC)/American Heart Association (AHA) published
  guidelines for exercise testing.

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Guidelines

• These guidelines stratify patients into risk
  categories based on age, gender, and type of
  chest pain when patients are to undergo stress
  tests for diagnostic reasons.
• Risk factors for coronary artery disease are not
  factored into the analysis except for patients
  with unstable angina (ACS).

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Guidelines
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Guidelines
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Guidelines

• Low risk (lt10 pretest probability) -
• No further testing needed
• Intermediate Risk (10-90 pp) -
• Stress Test Recommended
• High Risk (gt90 pp) -
• Do Not Stress, cardiac catheterization or
  cardiology consult

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Guidelines

• For Unstable Angina
• High Risk
• Cardiac Catheterization
• Intermediate Risk
• Stress after 2-3 days if asymptomatic (Class I)
• Stress after CIPs negative x 3 and no EKG
  changes (Class 2a)
• Low Risk
• Stress when asymptomatic for 8-12 hours

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Purpose

• To determine if patients admitted to the
  Trident/MUSC FMRP inpatient service with chest
  pain are receiving stress testing according to
  the ACC/AHA guidelines.

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Methods

• Retrospective chart review of patients admitted
  to the FMRP from 1/1/06 to 8/31/06 provided the
  baseline data.
• All charts were reviewed simultaneously by at
  least 2 members of the research team
• Charts were identified by patients who had
  troponins ordered
• Of these charts, those who presented with a chief
  complaint of chest pain fit criteria for the study

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Methods

• Data Recorded
• Age
• Gender
• Type of chest pain (typical, atypical,
  nonanginal, unstable angina)
• Contraindications
• Risk category
• Intervention (stress test, cardiac
  catheterization, cardiology consult, no
  intervention)

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Definition of Chest Pain

• Typical Anginal Pain is defined as
• substernal chest pain or discomfort that is
• provoked by exertion or emotional stress and
• relieved by rest and/or nitroglycerin.
• Atypical Anginal Pain meets 2 of these
  requirements
• Nonanginal Pain meets 1 requirement
• Unstable Angina
• Accelerating or progressively worsening chest
  pain that occurs at rest and is resistant to
  nitroglycerin

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Methods

• Based on a patients age, gender, and type of
  chest pain, the patient was assigned a risk
  category.
• It was also recorded if the patient received a
  stress test, and if this matched the
  recommendation that correlates with the risk
  category

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Methods

• The intervention of a Point-of-care reminder
  (concise, easy-to-read review of the ACC/AHA
  exercise testing guidelines) and education was
  provided to the inpatient team members on a
  bi-monthly basis
• After the intervention (5/07), monthly chart
  reviews on all patients meeting criteria are
  conducted for follow-up data collection.
• This project was approved as exempt research by
  the MUSC and Trident Medical Center IRBs

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Outcome Measures

• A comparison between the pre- and
  post-intervention data sets of the proportion of
  stress tests ordered that met the ACC/AHA
  guidelines.

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Results

• 396 charts total were reviewed for the
  pre-intervention data set
• 62 charts (15.7) met criteria for the study
• 32 patients were male, and 30 were female
• Overall mean age 51.6 years
• Male mean age 46.3 years
• Female mean age 57.4 years

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Types of Pain
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Risk Categories
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Males
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Females
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Overall
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Results

• A similar analysis of the post-intervention data
  will also be reported.
• Continuous variables will be analyzed using the
  Students T-test, and proportions will be
  analyzed using the Chi-squared test

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Discussion

• Management of chest pain is common on a family
  medicine inpatient service.
• Appropriately ordering stress tests is an
  important aspect of patient care.
• The FMRP inpatient service should reduce the
  number of stress tests ordered on high risk
  patients.

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Discussion

• Conversely, we need to increase the number of
  stress tests ordered on intermediate risk
  patients.
• The FMRP Inpatient service is generally not
  ordering stress tests for low risk patients,
  which follows the guidelines.
• Overall, more data is needed for the
  pre-intervention data set

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Conclusion

• Guidelines exist for exercise testing, and
  education regarding guidelines should improve
  appropriate use of the exercise test.

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