How long is a cath or stress test "good" for?

[sarahinromania]

So I have to give this lecture that answers a clinical question of my choosing. I was thinking about how we EMers tend to trust a negative stress test for about a year and negative caths for about 3 years when a patient comes in with chest pain but without EKG changes or a really scary history (old with lots of stents/post-CABG, diabetes+HTN+hyperchol+3 prior MIs). So I'm trying to find data to back this up and there does not appear to be any data that puts a good expiration date on any specific test.

Clinically, I find this frustrating because when admitting someone for a stress test recently, the admitting attending bit my head off because the guy had a negative cath from late 2004 and clearly couldn't be infarcting or require further risk stratification. I really wished then that I had some literature to back me up.

So I have a couple of questions:
1) What does your institution generally say about negative stress tests and negative caths regarding how long to trust them and under what clinical situations not to trust them at all?

2) Is anyone familiar with any studies that looked at five year outcomes of negative caths?

Thanks in advance for the insight.

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[diphenyl]

My understanding has always been with a neg cath, the pt is good for 3 years. With a neg stress test, 2 years. Frequently though when a patient tells me these thing I like to get the records in my hand for CYA purposes.
Although I will also add if a patient has been stented within the last 6 months there is cause for concern because generally if they make it out of the 6 month range without any major difficulty or reoclusion they're in the zone. Never believe a cardiologist that tells you that a stent that has been recently placed never can become occluded.

 

[southerndoc]

I've had 2 cases in the past year where a patient has had a negative stress test and came in with a STEMI. One of them had a negative stress test just the day prior.

Remember, a negative stress test means there is not a significant blockage to cause ischemia with increased workload. This often requires a stenosis of >90%. Those are not the plaques that will cause an MI. It's the plaque that's 30-50% that ruptures that causes the problem.

A negative stress test means absolutely nothing if given the right story. A negative cath is more reassuring, but I've seen negative caths have MI's too.

IF THE PATIENT HAS A CONCERNING STORY, THE PATIENT GETS ADMITTED. END OF STORY.

 

[BatmanMD]

I have to agree. Stress tests really don't mean a lot. If they have negative stress tests, but continue to have pain and "tell a good story", then I feel they need a cath. The newer CT scans may change this, but until standard of care changes....

If someone has a stent, and has chest pain, they get admitted. No questions. I don't care how long ago that stent was placed. To me, they had enough significant CAD to warrant a stent, so they deserve a stay at my hotel.

They can use a negative stress/cath for surgical clearance, but it does not change what I do (for the most part). Do what you feel is right.

 

[Seaglass]

Stress test - good sensitivity for 30 day events, overall sensitivity in the mid 80's for just about all of the test modalities.

Cath - no one knows. Like Southerndoc says it's the smaller plaque that ruptures and causes a STEMI. There was an abstract at ACEP 2 years ago and I don't know if it every got published. They followed people with a "clean cath" at ECU for a year and they had I think about a 5% cardiac event rate. Bottom line is it was a non-zero event rate so again it all comes back to the story.

 

[GeneralVeers]

For me the rules don't apply if they've had a recent stenting or CABG with no subsequent negative CATH within the last 6 months.

I admitted one lady who had stents placed about 2 months prior. She came in 3 times with chest pain, and twice she got discharged. On the third visit I admitted her and the cardiologist sent her to cath and she was already re-stenosed.

 

[kungfufishing]

Stress tests just don't do that much for me in the ED unless the story is pretty bad. I agree with Southern.

 

[diphenyl]

I wish my department had a cardiac observation unit. For those AM stress test admits, and serial enzymes. A guy who gives an impressive story but has no EKG changes, neg serial enzymes, and neg AM stress test, really doesn't need a bed upstairs when I have a guy in septic shock I'm babysitting for 20 hrs.