From the Guidelines
In a patient with central chest pressure and negative high sensitivity troponin, the next appropriate test would be stress imaging, preferably over exercise electrocardiogram (stress ECG), due to its greater diagnostic accuracy as suggested by the 2015 ESC guidelines 1. This approach is based on the principle of balancing diagnostic yield with procedural risk, especially in patients with intermediate pre-test probability of coronary artery disease. The 2015 ESC guidelines recommend stress imaging over exercise ECG for its superior diagnostic accuracy and prognostic value in patients without ischemic changes on 12-lead ECGs and negative cardiac troponins who are free of chest pain for several hours 1. Key considerations include:
- The patient's ability to exercise adequately and have a normal baseline ECG, which may influence the choice between stress ECG and other forms of stress imaging like radionuclide myocardial perfusion imaging.
- The presence of baseline ECG abnormalities that could interfere with the interpretation of stress ECG results, such as left bundle branch block or significant ST-T wave changes, which might necessitate the use of radionuclide myocardial perfusion imaging instead.
- Left heart catheterization is generally reserved for high-risk patients or those with strongly positive non-invasive tests, emphasizing the importance of a stepwise approach from non-invasive to more invasive testing. The most recent and highest quality evidence supports the use of stress imaging as the next step in the diagnostic workup for patients with central chest pressure and negative high sensitivity troponin, as outlined in the 2015 ESC guidelines 1.
From the Research
Next Steps in Diagnosis
Given a patient with central chest pressure and negative high sensitivity troponin, the next test to order would depend on various factors including the patient's medical history, risk factors, and the clinical presentation. However, based on the provided evidence, here are some considerations:
- Radionuclide Myocardial Perfusion Imaging (MPI): This test has been widely used for the evaluation of patients with known or suspected coronary artery disease (CAD) 2, 3. It can help identify areas of the heart that receive less blood flow, which may indicate CAD. The choice of radionuclide may influence the results of phase analysis in gated myocardial perfusion single-photon emission computed tomography images 4.
- Exercise Electrocardiogram (ECG): This test can be used to evaluate the heart's function under stress, but it may not be suitable for patients who are unable to exercise or achieve the required heart rate 5.
- Left Heart Catheterization: This is an invasive test that can provide detailed information about the coronary arteries, but it is usually reserved for patients with high-risk profiles or those who have already been diagnosed with CAD.
Key Considerations
When deciding on the next test to order, consider the following:
- The patient's symptoms and medical history
- The results of previous tests, including the negative high sensitivity troponin
- The patient's ability to exercise and achieve the required heart rate for an exercise ECG
- The potential benefits and risks of each test, including the invasive nature of left heart catheterization
Test Characteristics
Here are some key characteristics of each test:
- Radionuclide MPI:
- Non-invasive
- Can identify areas of reduced blood flow to the heart
- May require the use of radionuclides, which can have different effects on phase analysis 4
- Exercise ECG:
- Non-invasive
- Can evaluate the heart's function under stress
- May not be suitable for patients who are unable to exercise or achieve the required heart rate 5
- Left Heart Catheterization:
- Invasive
- Can provide detailed information about the coronary arteries
- Usually reserved for high-risk patients or those with diagnosed CAD