Multi-Slice Coronary Computed Tomography for Evaluation of Acute Chest Pain - Multi-Slice Coronary Computed Tomography for Evaluation of Acute Chest Pain

Description:

The goal of the study was to evaluate multi-slice computed tomography (MSCT) compared with standard diagnostic evaluation among low-risk patients presenting to the emergency department (ED) with acute chest pain.

Study Design

Study Design:

Patients Screened: 461
Patients Enrolled: 197
Mean Follow Up: 6 months
Mean Patient Age: Mean age 50 years
Female: 50

Patient Populations:

Chest pain or angina equivalent symptoms compatible with ischemia in the prior 12 hours; age ≥25 years; and a prediction of a low risk of infarction and/or complications

Exclusions:

Known coronary artery disease; electrocardiograms diagnostic of cardiac ischemia and/or infarction; elevated serum biomarkers on initial and 4-hour testing; previously known cardiomyopathy, with estimated ejection fraction ≤45%; contraindication to iodinated contrast and/or beta-blocking drugs; atrial fibrillation or markedly irregular rhythm; body mass index ≥39 kg/m2; renal insufficiency; or computed tomography imaging or contrast administration in the prior 48 hours

Drug/Procedures Used:

Patients presenting to the ED with chest pain were randomized to MSCT (n = 99) or standard diagnostic evaluation (n = 98). Patients randomized to MSCT who were found to have minimal disease were discharged; those with stenosis ≥70% underwent cardiac catheterization; patients with intermediate lesions or nondiagnostic scans underwent stress testing. Those in the standard care group underwent stress testing.

Principal Findings:

In the MSCT group, minimal or no coronary disease was found in 67.7% of patients, who were then discharged. Stenosis ≥70% was shown on the MSCT in 8.1% of patients who then underwent angiography. Intermediate stenosis was present in 13.1% of patients and nondiagnostic scans in 11.1% of patients in the MSCT group. Of these 24 patients, 21 (87.5%) had negative stress tests and were discharged, resulting in an overall ED discharge rate of 88.9% for the MSCT group. In the standard test group, stress tests were normal in 94.9% of patients, who were then discharged.

Invasive angiography was performed in 12.1% of the MSCT group (n = 9), of which 88.9% (8/9) had coronary disease (true positives); among the standard group, 7.1% underwent angiography. The correct diagnosis was identified in 97.0% of the MSCT group and 98.0% of the standard group.

Need for late cardiovascular re-evaluation trended lower in the MSCT group (2.0% vs. 7.1%, p = 0.10). Median time from randomization to definitive diagnostic was significantly shorter in the MSCT group (3.4 hours vs. 15.0 hours, p < 0.001). ED cost of care was lower in the MSCT group ($1,586 vs. $1,872, p < 0.001) despite similar costs for the MSCT procedure and the nuclear stress test ($507 vs. $538). There were no test-related complications in either group.

Interpretation:

Among low-risk patients presenting to the ED with acute chest pain, establishment or exclusion of coronary disease as the cause of chest pain was obtained with similar frequency using MSCT compared with standard diagnostic evaluation with nuclear stress testing.

While both methods of diagnosis resulted in similar diagnostic efficacy, use of the MSCT was associated with a lower ED cost compared with standard care as well as a shorter time to diagnosis. Additionally, the need for late cardiovascular re-evaluation trended lower in the MSCT group. With more than half of chest pain cases presenting to the ED for noncardiac etiologies, correct, timely, and cost-effective diagnostic tools are needed to "rule-in" and "rule-out" coronary disease.

The noninvasive MSCT can provide a high negative predictive value for exclusion of significant coronary artery disease at a lower cost than standard tools, making it a potentially useful diagnostic tool among patients at low risk for an acute coronary syndrome.

References:

Goldstein JA, Gallagher MJ, O'Neill WW, Ross MA, O'Neil BJ, Raff GL. A randomized controlled trial of multi-slice coronary computed tomography for evaluation of acute chest pain. J Am Coll Cardiol 2007;49:863-71.

Clinical Topics: Acute Coronary Syndromes, Noninvasive Imaging, Computed Tomography, Nuclear Imaging

Keywords: Coronary Artery Disease, Infarction, Acute Coronary Syndrome, Chest Pain, Tomography, X-Ray Computed, Cardiac Catheterization, Constriction, Pathologic, Emergency Service, Hospital, Exercise Test


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