Division of Cardiology, Department of Medicine, University of Washington, Seattle, Washington, USA.
Coron Artery Dis. 2021 May 1;32(3):184-190. doi: 10.1097/MCA.0000000000000928.
In response to the growing use of imaging-based cardiac stress tests in the evaluation of stable ischemic heart disease, professional societies have developed appropriate use criteria (AUC). AUC will soon be linked to reimbursement of advanced diagnostic imaging for Medicare beneficiaries via Clinical Decision Support Mechanisms (CDSMs). We sought to characterize the frequency and type of stress test utilization for chest pain referrals evaluated by cardiologists and determine appropriateness.
We conducted a retrospective review of new patient referrals seen by general cardiologists at an academic medical center between 2016 and 2017 for a diagnosis of chest pain or angina. Type of stress test ordered, if any, and its appropriateness (Appropriate, May be appropriate, and Rarely appropriate) were ascertained based on the 2013 multimodality AUC guideline document.
There were 535 total outpatients. After applying exclusion criteria, there were 349 patients in the sample; the average age was 52 ± 15 years and 53% were female. Most chest pain was nonanginal (65%). Pretest probability of CAD was most commonly intermediate (54%). A total of 183 patients (52%) were referred for stress testing. The majority of stress tests were considered appropriate (82%) by AUC.
Most patients referred to cardiologists for evaluation of chest pain or angina had nonanginal chest pain and an intermediate pretest probability of CAD. Stress testing was ordered in about half of these patients and the majority were considered appropriate by AUC. These findings suggest that indiscriminate use of CDSMs may not be warranted.
鉴于影像学心脏负荷试验在稳定型缺血性心脏病评估中的应用日益增多，专业学会制定了相应的适用标准（AUC）。AUC 即将通过临床决策支持机制（CDSM）与医疗保险受益人的高级诊断成像报销挂钩。我们旨在描述心脏病专家评估的胸痛转诊患者进行负荷试验的频率和类型，并确定其适宜性。
我们对 2016 年至 2017 年间在学术医疗中心就诊的普通心脏病专家新接诊的胸痛或心绞痛患者进行了回顾性研究。根据 2013 年多模态 AUC 指南文件，确定所开负荷试验的类型（如果有）及其适宜性（适宜、可能适宜和很少适宜）。
共有 535 名门诊患者。应用排除标准后，样本中有 349 名患者；平均年龄为 52±15 岁，53%为女性。大多数胸痛为非心绞痛性（65%）。CAD 的术前概率最常见为中度（54%）。共有 183 名（52%）患者被转诊进行负荷试验。AUC 认为大多数（82%）负荷试验是适宜的。
大多数因胸痛或心绞痛就诊的患者存在非心绞痛性胸痛和中度 CAD 术前概率。在这些患者中，约有一半进行了负荷试验，AUC 认为大多数是适宜的。这些发现表明，不加选择地使用 CDSM 可能没有必要。
