Evidence for Coronary CTA in the ED Builds

Results from a second trial reported here confirmed the value of initial coronary CT angiography (CCTA) scan in the emergency department for evaluation and management of lower-risk patients with chest pain.

With a randomized cohort of 1,000 patients, researchers found that an initial CCTA scan significantly shortened the hospital length of stay compared with standard care (mean 23 versus 31 hours, P<0.0002), Udo Hoffmann, MD, MPH, from Massachusetts General Hospital in Boston, reported here at the American College of Cardiology meeting.

And faster discharge did not pose a safety risk, as there were no missed cases of acute coronary syndrome within the first 72 hours post discharge and only two major adverse events at 28 days.

There also were no missed cases of acute coronary syndrome at 72 hours in the standard care arm, but that group had five major adverse events during the 28-day follow-up.

Earlier this week Harold I. Litt, MD, from the University of Pennsylvania in Philadelphia, reported at ACC12 similar results from the ACRIN PA study: earlier discharge and no events in the group randomized to the CCTA strategy.

The CT-STAT study, published last year in the Journal of the American College of Cardiology, also found favorable results for utilizing CCTA in the emergency department for low- to intermediate-risk patients. CT-STAT, however, compared CCTA to SPECT myocardial perfusion imaging.

The current study, ROMICAT II (Rule Out Myocardial Ischemia/Infarction Using Computer Assisted Tomography), as well as ACRIN PA, allowed local physicians to order the desired stress test: exercise, echocardiography, or SPECT.

"The clinical evidence from these three trials is consistent," said study discussant Matthew J. Budoff, MD, from UCLA Medical Center. "Physicians can feel confident discharging patients who have a negative CCTA scan."

The ROMICAT I study, a blinded observational study published last year in JACC: Cardiovascular Imaging, demonstrated that those cleared of a cardiac cause of their chest pain had very good prognosis over two years, Hoffmann said.

ROMICAT II randomized 1,000 acute chest pain patients from nine centers in the U.S. between April 2010 and January 2012 to the CCTA strategy or standard care. Follow-up was nearly 100% in both groups.

The mean age of patients was 54 and 46% were women. About 37% of patients had zero or one risk factor, 53% had two or three, and 10% had four or more. The chief patient complaint at presentation was anginal chest pain (90%).

At discharge, 8.6% and 6.4% of patients in the CCTA and standard care arms, respectively, had a diagnosis of acute coronary syndrome. Hoffmann noted the "excellent" agreement between the sites and independent adjudication for discharge diagnosis (96.5%, kappa 0.9).

Along with an overall absolute difference of 8 hours in length of stay between the two arms, when the final diagnosis was not acute coronary syndrome, CCTA allowed for even quicker discharge (17 versus 27 hours, P<0.001). There was no difference in length of stay when patients were diagnosed with acute coronary syndrome.