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A Randomized Controlled Trial

James E. Udelson, MD; Joni R. Beshansky, RN, MPH; Daniel S. Ballin, MD; James A. Feldman, MD; John L. Griffith, PhD; Gary V. Heller, MD, PhD; Robert C. Hendel, MD; J. Hector Pope, MD; Robin Ruthazer, MPH; Ethan J. Spiegler, MD; Robert H. Woolard, MD; Jonathan Handler, MD; Harry P. Selker, MD, MSPH

JAMA. 2002;288:2693-2700.

Context  Observational studies of acute myocardial perfusion imaging in emergency department (ED) patients with chest pain have suggested high sensitivity and negative predictive value for acute cardiac ischemia, but use of this method has not been prospectively tested.

Objective  To assess whether incorporating acute resting perfusion imaging into an ED evaluation strategy for patients with suspected acute ischemia but no initial electrocardiogram (ECG) changes diagnostic of acute ischemia improves clinical decision making for initial ED triage.

Design, Setting, and Patients  Prospective, randomized controlled trial conducted at 7 academic medical centers and community hospitals between July 1997 and May 1999 among 2475 adult ED patients with chest pain or other symptoms suggestive of acute cardiac ischemia and with normal or nondiagnostic initial ECG results.

Intervention  Patients were randomly assigned to receive either the usual ED evaluation strategy (n = 1260) or the usual strategy supplemented with results from acute resting myocardial perfusion imaging using single-photon emission computed tomography with injection of 20 to 30 mCi of Tc-99m sestamibi (n = 1215), interpreted in real time by local staff physicians and with results provided to the ED physician for incorporation into clinical decision making.

Main Outcome Measure  Appropriateness of triage decision either to admit to hospital/observation or to discharge directly home from the ED.

Results  Among patients with acute cardiac ischemia (ie, acute myocardial infarction [MI] or unstable angina; n = 329), there were no differences in ED triage decisions between those receiving standard evaluation and those whose evaluation was supplemented by a sestamibi scan. Among patients with acute MI (n = 56), 97% vs 96% were hospitalized (relative risk [RR], 1.00; 95% confidence interval [CI], 0.89-1.12), and among those with unstable angina (n = 273), 83% vs 81% were hospitalized (RR, 0.98; 95% CI, 0.87-1.10). However, among patients without acute cardiac ischemia (n = 2146), hospitalization was 52% with usual care vs 42% with sestamibi imaging (RR, 0.84; 95% CI, 0.77-0.92).

Conclusions  Sestamibi perfusion imaging improves ED triage decision making for patients with symptoms suggestive of acute cardiac ischemia without obvious abnormalities on initial ECG. In this study, unnecessary hospitalizations were reduced among patients without acute ischemia, without reducing appropriate admission for patients with acute ischemia.

Author Affiliations: Divisions of Clinical Care Research (Drs Udelson, Griffith, and Selker, and Mss Beshansky and Ruthazer) and Cardiology (Dr Udelson), and Department of Emergency Medicine (Dr Ballin), Tufts-New England Medical Center, Boston, Mass; Department of Emergency Medicine, Boston Medical Center, Boston (Dr Feldman); Division of Cardiology, Hartford Hospital, Hartford, Conn (Dr Heller); Division of Cardiology (Dr Hendel) and Department of Emergency Medicine (Dr Handler), Northwestern Memorial Hospital, Chicago, Ill; Department of Emergency Medicine, Baystate Medical Center, Springfield, Mass (Dr Pope); Division of Nuclear Medicine, St Agnes Health Care System, Baltimore, Md (Dr Spiegler); and Department of Emergency Medicine, Rhode Island Hospital, Providence (Dr Woolard).

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