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J Nucl Cardiol. 2018 Aug;25(4):1274-1282. doi: 10.1007/s12350-016-0774-y. Epub 2017 Jan 12.

Comparative efficiency of exercise stress testing with and without stress-only myocardial perfusion imaging in patients with low-risk chest pain.

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Division of Cardiovascular Diseases, Department of Cardiology, Icahn School of Medicine at Mount Sinai, Mount Sinai Heart at Mount Sinai Beth Israel, First Avenue at 17th Street, 5 Baird Hall, New York, NY, 10003, USA.
Department of Medicine, North Shore University Hospital, Manhasset, NY, USA.
Department of Medicine, North Shore University Hospital, Manhasset, NY, USA.
Department of Cardiology, Long Island Jewish Medical Center, New Hyde Park, NY, USA.
Department of Emergency Medicine, Northwell Hofstra University School of Medicine, Uniondale, NY, USA.
Division of Cardiology, Department of Medicine, St. John's Episcopal Hospital, Far Rockaway, NY, USA.



To compare major adverse cardiac event (MACE), downstream resource utilization, and direct cost of care for low-risk chest pain patients observed in the clinical decision unit (CDU) with exercise treadmill testing (ETT) and with stress-only myocardial perfusion imaging (sMPI).


CDUs are poised to increase efficiency and resource utilization. However, the optimal testing strategy that would assure favorable outcomes while decreasing cost is not defined.


1016 subjects from 2 locations were propensity score-matched (PSM) by age, gender, pre-test likelihood, Duke treadmill score, and test results. Outcomes were length of stay >24 hours, MACE (acute coronary syndrome, revascularization, cardiac death), downstream resource use (admission for chest pain, repeat testing, angiography), and mean direct cost per patient.


PSM yielded 680 patients (340 matches). 98% of all tests were normal. 96.6% of patients were discharged from the CDU within 24 hours but twice as many exceeded 24 hours in the sMPI group. There were no cardiac deaths. MACE rate was 1.47% at 72 hours and 1% at 1 year. Downstream resource use was 4.82% at 72 hours, and 7.69% at 1 year. The sMPI group was event-free longer than the ETT group reflecting less repeat testing. The mean direct cost was 30% higher for sMPI ($3168.70) vs. ETT ($2226.96).


Low-risk chest pain patients in the observation unit had low MACE rate, not different for ETT vs. sMPI. The majority of ETT and sMPI tests were normal. The sMPI reduced additional testing, but resulted in greater expense and longer stay.


Exercise stress testing; low-risk chest pain; observation unit; outcomes; stress-only myocardial perfusion imaging


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