Home > Cardiac Imaging, CT coronary angiography, Journal Club > Journal Club 8 August 2012

Journal Club 8 August 2012

Paper

Coronary CT Angiography versus Standard Evaluation in Acute Chest Pain

Presenter

JFY

Summary (abstract from paper)

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 standardevaluation
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.

Comments

There was general discussion around different diagnostic algorithms, definitions of acceptable risk, various accelerated diagnostic protocols, radiation exposure and stochastic risk (esp. cumulative exposures and ‘vulnerable’ group). [Cardiology and Emergency Physician input]

The editorial is available here

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