Are Routine Chest Radiographs Necessary in all Patients with Acute Coronary Syndrome?
Date First Published:
August 3, 2021
Last Updated:
August 3, 2021
Report by:
Kaitlyn Beels MD, Christian Kolacki MD, EM Senior Resident, EM Faculty (Spectrum Health - Michigan State University Emergency Medicine Residency Program, Grand Rapids, MI)
Search checked by:
Jeffrey Jones, Spectrum Health - Michigan State University Emergency Medicine Residency Program, Grand Rapids, MI
Three-Part Question:
In [adult patients with chest pain and possible acute coronary syndrome] what is the [diagnostic utility] of [routine chest radiographs]?
Clinical Scenario:
The patient is a 52-year-old male with history of hypertension who presents to the emergency department (ED) with complaints of chest pain that started 1 hour prior to arrival. On arrival to the ED, he appears comfortable with stable vital signs, and has a normal physical exam. His pain is reported as mild, sharp and substernal, non-radiating, and worse with certain movements but not exertion. His pain resolves after 324 mg chewable aspirin and a lidocaine patch. His lab workup and elecrocardiogram are normal. The patient has a heart score of 2. You consider ordering a chest x-ray (CXR) prior to discharging the patient.
Search Strategy:
Medline 1966-08/21 using PubMed, Cochrane Library (2021), and Embase
Search Details:
[(emergency medical services OR emergency department OR emergency services) AND (chest pain/diagnostic imaging OR heart diseases/diagnostic imaging OR acute coronary syndrome/diagnostic imaging)]
Outcome:
51 studies were identified; three studies addressed the clinical question.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Failure of prospective validation and derivation of a refined clinical decision rule for chest radiography in emergency department patients with chest pain and possible acute coronary syndrome Poku J, Bellamkonda-Athmaram V, Bellolio M, Nestler D, Stiell I, Hess E. Sep-12 USA | Patients over 24 years of age with a primary complaint of chest pain and possible acute coronary syndrome (ACS) | Prospective validation of clinical decision rule (CDR) | Diagnostic accuracy of a CDR for chest radiography | Sensitivity was 100% and specificity was 11.5%; positive predictive value was 6.7% | Single center study, small sample size, study did not determine when chest radiograph was used to narrow differential diagnosis |
| Validation of a clinical decision rule: Chest X-ray in patients with chest pain and possible acute coronary syndrome. Goldschlager R, Roth H, Solomon J, Robson S, Green J, Green S, Spanger M, Gunn R, Cameron P. Mar-14 USA | Patients over the age of 18 presenting with chest pain who had a CXR and troponin level ordered | Retrospective cohort | Diagnostic accuracy of Canadian ACS guidelines for appropriate CXR use | Sensitivity of 80% and a specificity of 50%; positive predictive value of 18% | Retrospective study; small sample size |
| Routine chest radiography in uncomplicated suspected acute coronary syndrome rarely yields significant pathology Ng JJ, Taylor DM. Dec-08 USA | Adult patients with suspected ACS | Retrospective cohort | Proportion of patients who had an abnormal chest radiograph | 130 of the 158 patients (82%) had CXR | Retrospective study; small sample size; discrepancy between the ED physician and radiologist reports |
| Proportion of radiographs that changed management | 40 (31%) of which had some abnormality; only 3 results altered management |
Author Commentary:
Acute coronary syndrome (ACS) account for a significant number of U.S. ED visits annually. The diagnostic evaluation typically includes laboratory investigation, electrocardiogram, and a CXR. The utility of the CXR in ACS work-up has been researched; rarely do the results yield significant results or alter management of the patient. Previous studies suggest that between 20-30% of patients with chest pain have abnormal chest radiographs, but these radiographic abnormalities lead to a change in management in only 2-3%. There is no current universal clinical decision rule regarding when to order a CXR in the setting of ACS chest pain. Current guidelines that attempt to reduce the number of CXRs performed do so at the expense of missing significant CXR findings in 2-3% of patients. There is room for further research in this area to better establish which patient population and/or risk factors should prompt CXR to be included in the chest pain workup.
Bottom Line:
Current decision rules and ACS guidelines have the potential to reduce the numbers of unnecessary CXRs performed in ACS work-up. However, this would come at the expense of missing significant CXR findings in 2-3% of patients.
References:
- Poku J, Bellamkonda-Athmaram V, Bellolio M, Nestler D, Stiell I, Hess E. . Failure of prospective validation and derivation of a refined clinical decision rule for chest radiography in emergency department patients with chest pain and possible acute coronary syndrome
- Goldschlager R, Roth H, Solomon J, Robson S, Green J, Green S, Spanger M, Gunn R, Cameron P. . Validation of a clinical decision rule: Chest X-ray in patients with chest pain and possible acute coronary syndrome.
- Ng JJ, Taylor DM. . Routine chest radiography in uncomplicated suspected acute coronary syndrome rarely yields significant pathology