Comparison of Early Dobutamine Stress Echocardiography and Exercise Electrocardiographic Testing for Management of Patients Presenting to the Emergency Department With Chest Pain Gaetano Nucifora, MD*, Luigi P. Badano, MD, Nizal Sarraf-Zadegan, MD, Apostolos Karavidas, MD, Giuseppe Trocino, MD, Giorgio Scaffidi, MD, Gianni Pettinati, MD, Costantino Astarita, MD, Vitas Vysniauskas, MD, Dario Gregori, PhD, Baris Ilerigelen, MD, Ricarda Marinigh, MD, and Paolo M. Fioretti, MD, PhD This study compared the cost-effectiveness of dobutamine-atropine stress echocardiogra- phy (DASE) and electrocardiographic exercise testing (EET) implemented in emergency department accelerated diagnostic protocols for the early stratification of low-risk patients presenting with acute chest pain (ACP). One hundred ninety-nine patients with ACP, nondiagnostic electrocardiographic results, and negative biomarker results were random- ized to DASE (n  110) or EET (n  89) <6 hours after emergency department presen- tation. Patients with negative risk assessment results were immediately discharged and followed for 2 months. Ninety patients (82%) in the DASE arm and 78 (88%) in the EET arm were discharged after the diagnosis of nonischemic ACP. The mean lengths of stay in the hospital were 23  12 and 31  23 hours in the DASE and EET arms, respectively (p  0.01). No 2-month follow-up events occurred in DASE patients, and the event rate was significantly higher in EET patients (0% vs 11%, p  0.004). The DASE strategy showed lower costs compared with the EET strategy at 1-month ($1,026  $250 vs $1,329  $1,288, p  0.03) and 2-month ($1,029  253 vs $1,684  $2,149, p  0.005) follow-up. In conclusion, early DASE in emergency department triage of low-risk patients with ACP is safe and reduces costs of care compared to EET. © 2007 Elsevier Inc. All rights reserved. (Am J Cardiol 2007;100:1068 –1073) We designed a prospective, randomized, multicenter trial to compare the use of dobutamine-atropine stress echo- cardiography (DASE) and electrocardiographic exercise testing (EET) implemented in emergency department ac- celerated diagnostic protocols in terms of hospital admis- sion rate reduction, length of stay, and total costs for patients needing admission for the evaluation of acute chest pain (ACP). Methods The Assessment of Cost-Effectiveness of Several Strategies of Early Diagnosis in Patients With ACP and Non Conclu- sive Electrocardiogram (ASSENCE) study was designed as a parallel randomized trial and was performed in 10 emer- gency departments in 5 different countries (see Appendix). The study protocol is shown in Figure 1. All patients pre- senting to emergency departments with ACP received evalua- tions consisting of histories, physical examinations, electrocar- diography, 2-dimensional echocardiography, blood cell counts and chemistry, serial measurements of myocardial injury bi- omarkers, chest x-rays, and any further testing deemed neces- sary by the attending physicians. Exclusion and inclusion criteria for enrollment in the study are listed in Table 1. Informed consent forms for study enrollment and management of the clinical data were sub- mitted to patients who fulfilled these criteria. The protocol was approved by the ethics committee of all participating centers and conformed to the ethical guidelines of the Dec- laration of Helsinki. Patients who fulfilled inclusion and exclusion criteria and gave informed consent were randomly assigned to the DASE arm or the EET arm. According to study protocol, the 2 tests had to be performed 18 hours after random- ization. All patients with negative DASE or EET results were immediately discharged after the tests. In case of insufficient acoustic windows on echocardiography, pa- tients were followed according to the intention-to-treat pro- tocol. Patients with positive DASE or EET results were admitted to coronary care units. Blood samples were taken at admission for the determi- nation of myocardial injury biomarkers (creatine kinase-MB mass or subfraction, cardiac troponin level). These tests were repeated 4 hours later. For patients who presented 2 hours after the onset of ACP, these tests were performed for a third time 6 hours after the onset of pain to obtain myo- cardial injury biomarker determinations in all patients 6 hours after the onset of pain. Twelve-lead electrocardiography was performed at ad- mission, before randomization, and whenever patients had new episodes of ACP during their in-hospital stays. IRCAB Foundation, Udine, Italy. Manuscript received March 22, 2007; revised manuscript received and accepted May 8, 2007. *Corresponding author: Tel: 39-432552441; fax: 39-432482353. E-mail address: gnucifora@cardionet.it (G. Nucifora). 0002-9149/07/$ – see front matter © 2007 Elsevier Inc. All rights reserved. www.AJConline.org doi:10.1016/j.amjcard.2007.05.027