Coronary CT Angiography versus Standard Evaluation in Acute Chest Pain

TLDR

It is unclear whether an evaluation incorporating coronary computed tomographic angiography (CCTA) is more effective than standard evaluation in the emergency department for patients with symptoms suggestive of acute coronary syndromes. The multicenter randomized trial enrolled 1,000 adults aged 40–74 with suspected ACS but no ECG changes or positive troponin, assigning them to early CCTA or standard evaluation, and compared primary endpoint of hospital length of stay with secondary endpoints of ED discharge rates, 28‑day major adverse events, cumulative costs, and safety (undetected ACS). CCTA shortened hospital stay by 7.6 h, increased ED discharge rates (47 % vs 12 %), produced no undetected ACS or 28‑day major events, but led to more downstream testing, higher radiation, and similar overall costs compared with standard evaluation. Funded by the National Heart, Lung, and Blood Institute (ClinicalTrials.gov NCT01084239).

Abstract

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.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.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).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.).