Coronary CT Angiography versus Standard Evaluation in Acute Chest Pain

Abstract

Background It is unclear whether an evaluation incorporating coronary computed tomographic angiography (CCTA) is more effective than standard evaluation in the emergency department in patients with symptoms suggestive of acute coronary syndromes. Methods In this multicenter trial, we randomly assigned patients 40 to 74 years of age with symptoms suggestive of acute coronary syndromes but without ischemic electrocardiographic changes or an initial positive troponin test to early CCTA or to standard evaluation in the emergency department on weekdays during daylight hours between April 2010 and January 2012. The primary end point was length of stay in the hospital. Secondary end points included rates of discharge from the emergency department, major adverse cardiovascular events at 28 days, and cumulative costs. Safety end points were undetected acute coronary syndromes. Results The rate of acute coronary syndromes among 1000 patients with a mean (±SD) age of 54±8 years (47% women) was 8%. After early CCTA, as compared with standard evaluation, the mean length of stay in the hospital was reduced by 7.6 hours (P<0.001) and more patients were discharged directly from the emergency department (47% vs. 12%, P<0.001). There were no undetected acute coronary syndromes and no significant differences in major adverse cardiovascular events at 28 days. After CCTA, there was more downstream testing and higher radiation exposure. The cumulative mean cost of care was similar in the CCTA group and the standard-evaluation group ($4,289 and $4,060, respectively; P=0.65). Conclusions In patients in the emergency department with symptoms suggestive of acute coronary syndromes, incorporating CCTA into a triage strategy improved the efficiency of clinical decision making, as compared with a standard evaluation in the emergency department, but it resulted in an increase in downstream testing and radiation exposure with no decrease in the overall costs of care. (Funded by the National Heart, Lung, and Blood Institute; ROMICAT-II ClinicalTrials.gov number, NCT01084239.)

A comparison of coronary CTA and stress testing using high-efficiency SPECT MPI for the evaluation of chest pain in the emergency department

“…14,16,17 The current study confirmed the significant time savings of CTA in efficiently triaging patients. In the ACRIN PA 4005 and ROMICAT-II studies, direct discharge from the ED was more common in the CTA group although the use of observation units clouds the picture to some extent as ''admission to the hospital'' in ROMICAT-II was reduced only modestly with 25.4% vs 31.7%.…”

“…[11][12][13] Several recent randomized studies and two metaanalyses have been published examining the diagnostic utility of CTA in evaluating patients in the ED with possible ACS. [14][15][16][17][18][19] Recent CTA studies have suggested efficient triage of patients, safe expedited discharge from the ED, cost effectiveness, and lower radiation dose when compared to standard diagnostic evaluation including MPI. However, this comparison has been to older conventional Na-I SPECT cameras using traditional rest-stress protocols.…”

Cardiac risk factors and risk scores vs cardiac computed tomography angiography: a prospective cohort study for triage of ED patients with acute chest pain

“…As noted in the introduction, randomized trials have demonstrated excellent negative predictive value for cCTA in evaluation of patients presenting to the ED with chest pain, and have suggested that cCTA may be more cost-effective than traditional stress testing for rapid discharge of these ED chest pain patients. [14][15][16][17][18] Another significant advantage of cCTA over stress testing is the ability to assess simultaneously for non-cardiac etiologies of chest pain in the mediastinum, lungs and chest wall. In appropriate clinical situations where both cardiac and noncardiac vascular causes of chest pain are suspected, a "triple rule-out" CTA study can evaluate the aorta, coronary arteries and pulmonary arteries and expedite discharge of up to 75% of patients presenting to the ED with atypical chest pain.…”

“…14,15 Three randomized multicenter trials have recently confirmed cCTA as a safe and cost-effective diagnostic test to discharge low-risk chest pain patients. 16,17,18 These randomized multicenter studies have opened the possibility of widespread cCTA testing for low risk ED patients presenting with chest pain, though the utility of such testing depends upon the pre-test probability of disease. 19 Many practicing physicians remain convinced that accurate evaluation of traditional risk factors and clinical presentation can be used for triage of the low risk ED patient and to limit the number of ED patients who should be referred for cCTA.…”

Myocardial CT perfusion imaging for ischemia detection

“…In the setting of suspected stable CAD, large multicenter trials such as the PROMISE (4) and SCOT-HEART (5) have demonstrated that CCTA is clinically useful as an alternative or in addition to functional testing. In the triage of patients with acute chest pain, also large trials such as CT-STAT (6), ACRIN-PA (7), ROMICAT II (8), CT-COMPARE (9) and real world scenario (10,11) in where CCTA was rivaled with standard of care, have demonstrated that negative CT findings allowed to safety rule out CAD and identify patients eligible for early discharge from the emergency department.…”