Integration of CTA in the Diagnostic Workup of New Onset Chest Pain in Clinical Practice

Abstract

Background. Recently, NICE guidelines recommend the use of computed tomographic angiography (CTA) as the first line of investigation for new onset chest pain. We sought to evaluate the impact of the integration of CTA in the diagnostic workup, as either a first- or second-line of investigation, in the clinical practice for patients presenting with new onset chest pain, with suspicion that it may be due to coronary artery disease (CAD). Method and Results. From 2014 to 2016, 208 outpatients (mean age 63.8 ± 12.7, 37% female) with an unknown CAD diagnosis were evaluated. About half (n=106, 51%) received usual testing care plus CTA as a second-line investigation (group A), while the other half (n=102, 49%) received CTA as a first-line investigation (group B). Care decisions and test interpretations were made by the attending physician. Obstructive CAD (O-CAD) was defined as >50% stenosis in the principal branch. As determined by CTA, the rates of CAD in group A vs. group B were the following (P=0.001): 31.1% vs. 27.4% for normal/minimal CAD; 42.5% vs. 63.7% for no O-CAD; and 26.4% vs. 8.8% with O-CAD. Based on a diagnostic result of no O-CAD, invasive angiography was cancelled in 42.6% (n=45) of group A patients, and additional functional tests were cancelled for the same reason in 63.7% (n=65) of group B patients, without adverse events at median 3-year. The average diagnostic cost for patients in our study was lower in group B (206 vs. 324.42 euro; P<0.0001). Conclusions. In clinical practice, CTA, as a first- or second-line investigation, most commonly detected no O-CAD in new onset chest pain patients, leading us to safely avoid unnecessary ICA or additional functional tests. The use of CTA as a first-line investigation also appears to be cost saving, but its cost-effectiveness remains to be demonstrated in larger studies.

Evaluation of stable chest pain following emergency department presentation: Impact of first‐line cardiac computed tomography diagnostic strategy in an Australian setting

“…In line with this, CTCA also reduced the time from ED to ICA. Reduced functional testing has also been shown in other studies of CTCA in outpatients with chest pain 27,28 …”

The Value of a Coronary Computed Tomography Angiography plus Stress Cardiac Magnetic Resonance Imaging Strategy for the Evaluation of Patients with Chronic Coronary Syndrome

“…In this study, we found that a CCTA plus S-CMR strategy works very well in clinical practice. First, we can safely avoid unnecessary further examination in a significant proportion of CCS patients showing no or only minimal plaques at CCTA, confirming its high negative predictive value [ 18 ]. More importantly, for CCS patients with intermediate coronary plaques at CCTA, the strategy of adding S-CMR appears to be effective, leading us to refine the selection of patients needing ICA and coronary revascularization, who in our study population were as many as a quarter of the patients.…”

Speckle Tracking Echocardiography: Early Predictor of Diagnosis and Prognosis in Coronary Artery Disease

“…Therefore, in the last years, advanced imaging modalities have been proposed for the evaluation of CAD: while cardiac computed tomography (CCT) use has been recommended in the last ESC guidelines [ 10 , 11 ] and National Institute for Health and Care Excellence (NICE) for younger patients with chest pain and low pretest probability of CAD, due to its greater anatomic insights and high negative predictive value (NPV) [ 15 ], cardiac magnetic resonance could be preferred for prognostic purposes in ACS and CCS [ 16 ]. In fact, in a cohort of 206 patients, the application of CCT, as first- or second-line investigation, allowed to spare 42.6% unnecessary invasive coronary angiography (ICA) and 63.7% of additional functional test (when used as first-line exam) [ 17 ]. However, CCT pitfalls still remain high costs and have low availability and a need of a specific trained team of operators and clinicians.…”