Randomized comparison between clinical evaluation plus N-terminal pro–B-type natriuretic peptide versus exercise testing for decision making in acute chest pain of uncertain origin

Sanchis, Juan; Bosch, Xavier; Bodí, Vicente; Núñez, Julio; Doltra, Ada; Heras, Magda; Mainar, Luis; Santas, Enrique; Bragulat, Ernest; García-Alvarez, Ana; Carratalá, Arturo; Llácer, Angel

doi:10.1016/j.ahj.2009.11.010

« Previous Next »American Heart Journal
Volume 159, Issue 2 , Pages 176-182, February 2010

Randomized comparison between clinical evaluation plus N-terminal pro–B-type natriuretic peptide versus exercise testing for decision making in acute chest pain of uncertain origin

Juan Sanchis, MD
- Cardiology Department, University Clinic Hospital, University of Valencia, Valencia, Spain
- Reprint requests: Juan Sanchis, MD, Servei de Cardiologia, Hospital Clínic Universitari, Blasco Ibáñez 17, 46010 València, Spain.
Xavier Bosch, MD
- Cardiology Department, Hospital Clínic, University of Barcelona, Barcelona, Spain
Vicente Bodí, MD
- Cardiology Department, University Clinic Hospital, University of Valencia, Valencia, Spain
Julio Núñez, MD
- Cardiology Department, University Clinic Hospital, University of Valencia, Valencia, Spain
Ada Doltra, MD
- Cardiology Department, Hospital Clínic, University of Barcelona, Barcelona, Spain
Magda Heras, MD
- Cardiology Department, Hospital Clínic, University of Barcelona, Barcelona, Spain
Luis Mainar, MD
- Cardiology Department, University Clinic Hospital, University of Valencia, Valencia, Spain
Enrique Santas, MD
- Cardiology Department, University Clinic Hospital, University of Valencia, Valencia, Spain
Ernest Bragulat, MD
- Cardiology Department, Hospital Clínic, University of Barcelona, Barcelona, Spain
Ana García-Alvarez, MD
- Cardiology Department, Hospital Clínic, University of Barcelona, Barcelona, Spain
Arturo Carratalá, MD
- Clinical Biochemistry Department, University Clinic Hospital, Valencia, Spain
Angel Llácer, MD
- Cardiology Department, University Clinic Hospital, University of Valencia, Valencia, Spain

Received 28 July 2009; accepted 12 November 2009.

Background

Exercise testing constitutes the usual tool for decision making in chest pain units. This policy implies logistical constrains. Our aim was to evaluate a new strategy, combining a clinical risk score and N-terminal pro–B-type natriuretic peptide (NT-proBNP), in patients presenting to the emergency department with chest pain, without ischemic electrocardiogram changes or troponin elevation.

Methods

A total of 320 patients were randomized to either usual management, involving exercise testing, or a new strategy combining a clinical risk score and NT-proBNP without exercise testing. In the usual management, discharge decision was guided by the result of exercise test. In the new strategy, those patients with low clinical risk score and NT-proBNP were directly discharged. The primary outcome was hospitalization at the index episode. Secondary outcomes were cardiac events at 1 year.

Results

A total of 110 patients (69%) were hospitalized using usual management in comparison with 90 (56%) in the new strategy (P = .03). There were no differences in death or myocardial infarction (n = 11, 6.9% vs n = 6, 3.8%, P = .3) or cardiac events (n = 38, 24% vs n = 28, 18%, P = .2). Revascularizations at the index episode were more frequent under usual management (18% vs 8%, P = .01), although the new strategy was associated with higher rate of planned postdischarge revascularizations (0.6% vs 5%, P = .04).

Conclusions

A strategy combining clinical history and NT-proBNP is simpler and reduced initial emergency hospitalizations in patients with chest pain, in comparison with the usual strategy involving exercise testing. Larger studies to assess its impact on long-term hard end points are needed. (ClinicalTrials.gov NCT00493844)