Importance The incremental benefit of noninvasive testing in addition to clinical evaluation (history, physical examination, an electrocardiogram [ECG], and biomarker assessment) vs clinical evaluation alone for patients who present to the emergency department (ED) with acute chest pain is unknown. Objective To examine differences in outcomes with clinical evaluation and noninvasive testing (coronary computed tomographic angiography [CCTA] or stress testing) vs clinical evaluation alone. Design, Setting, and Participants This study was a retrospective analysis of data from the randomized multicenter Rule Out Myocardial Ischemia/Infarction by Computer Assisted Tomography (ROMICAT-II) trial. Data for 1000 patients who presented with chest pain to the EDs at 9 hospitals in the United States were evaluated. Interventions Clinical evaluation plus noninvasive testing (CCTA or stress test) vs clinical evaluation alone. Main Outcomes and Measures Primary outcome was length of stay (LOS). Secondary outcomes included hospital admission, direct ED discharge, downstream testing, rates of invasive coronary angiography, revascularization, major adverse cardiac events (MACE), repeated ED visit or hospitalization for recurrent chest pain at 28 days, and cost. Safety end points were missed acute coronary syndrome (ACS) and cumulative radiation exposure during the index visit and follow-up period. Results Of the 1000 patients randomized, 118 patients (12%) (mean [SD] age, 53.2 [7.8]; 49 [42%] were female) did not undergo noninvasive testing, whereas 882 (88%) (mean [SD] age, 54.4 [8.14] years; 419 [48%] were female) received CCTA or stress testing. There was no difference in baseline characteristics or clinical presentation between groups. Patients who underwent clinical evaluation alone experienced a shorter LOS (20.3 vs 27.9 hours; P < .001), lower rates of diagnostic testing (P < .001) and angiography (2% vs 11%; P < .001), lower median costs ($2261.50 vs $2584.30; P = .009), and less cumulative radiation exposure (0 vs 9.9 mSv; P < .001) during the 28-day study period. Lack of testing was associated with a lower rate of diagnosis of ACS (0% vs 9%; P < .001) and less coronary angiography and percutaneous coronary intervention (PCI) during the index visit (0% vs 10%; P < .001, and 0% vs 4%; P = .02, respectively). There was no difference in rates of PCI (2% vs 5%; P = .15), coronary artery bypass surgery (0% vs 1%; P = .61), return ED visits (5.8% vs 2.8%; P = .08), or MACE (2% vs 1%; P = .24) in the 28-day follow-up period. Conclusions and Relevance In patients presenting to the ED with acute chest pain, negative biomarkers, and a nonischemic ECG result, noninvasive testing with CCTA or stress testing leads to longer LOS, more downstream testing, more radiation exposure, and greater cost without an improvement in clinical outcomes. Trial Registration clinicaltrials.gov Identifier: NCT01084239

中文翻译：

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急性胸痛中的无创心脏检测与单独的临床评估

重要性 对于因急性胸痛到急诊科 (ED) 就诊的患者，无创检查与临床评估（病史、体格检查、心电图 [ECG] 和生物标志物评估）相比的增量益处与单独的临床评估相比尚不清楚。目的检查临床评估和无创测试（冠状动脉计算机断层扫描血管造影 [CCTA] 或压力测试）与单独的临床评估结果的差异。设计、设置和参与者 本研究是对随机多中心计算机辅助断层扫描排除心肌缺血/梗死 (ROMICAT-II) 试验数据的回顾性分析。评估了美国 9 家医院的 1000 名胸痛患者的数据。干预 临床评估加无创测试（CCTA 或压力测试）与单独的临床评估。主要结果和测量主要结果是住院时间（LOS）。次要结果包括入院、直接 ED 出院、下游测试、侵入性冠状动脉造影的发生率、血运重建、主要不良心脏事件 (MACE)、重复 ED 就诊或 28 天时因胸痛复发而住院，以及费用。安全终点是在初次就诊和随访期间错过的急性冠脉综合征 (ACS) 和累积辐射暴露。结果 在随机分配的 1000 名患者中，118 名患者 (12%)（平均 [SD] 年龄，53.2 [7.8]；49 [42%] 名女性）未接受无创检测，而 882 名 (88%)（平均 [SD] 54.4 [8.14] 岁；419 [48%] 是女性）接受了 CCTA 或压力测试。两组之间的基线特征或临床表现没有差异。仅接受临床评估的患者的 LOS 较短（20.3 小时 vs 27.9 小时；P < .001）、诊断测试率（P < .001）和血管造影率较低（2% vs 11%；P < .001）、中位数较低在 28 天的研究期间，成本（2261.50 美元对 2584.30 美元；P = .009），以及更少的累积辐射暴露（0 对 9.9 毫希；P < .001）。缺乏检测与较低的 ACS 诊断率（0% 对 9%；P < .001）和第一次就诊期间冠状动脉造影和经皮冠状动脉介入治疗 (PCI) 的减少有关（0% 对 10%；P < .001）。 001，以及 0% 与 4%；分别为 P = .02）。PCI（2% 对 5%；P = .15）、冠状动脉搭桥手术（0% 对 1%；P = .61）、急诊复诊率（5.8% 对 2.8%；P = .08), 或 MACE（2% 对 1%；P = .24）在 28 天的随访期内。结论和相关性 对于因急性胸痛、阴性生物标志物和非缺血性心电图结果到 ED 就诊的患者，使用 CCTA 或压力测试的无创检测会导致更长的 LOS、更多的下游检测、更多的辐射暴露和更高的成本，而没有改善临床结果。试验注册clinicaltrials.gov 标识符：NCT01084239