CT Angiography for Safe Discharge of Patients With Possible Acute Coronary Syndromes

Study Questions:

Does coronary computed tomographic angiography (CCTA) in the emergency department allow safe early discharge of patients presenting with chest pain?

Methods:

Patients with possible acute coronary syndrome presenting to one of five centers in the United States who were thought to be at low to intermediate risk were randomly assigned in a 2:1 ratio to either undergo or not undergo CCTA. Patients >30 years of age with a TIMI (Thrombolysis in Myocardial Infarction) risk score of 0-2 and signs or symptoms warranting admission or testing were eligible. The primary outcome was safety, assessed in the subgroup of patients with a negative CCTA, and defined as the absence of myocardial infarction and cardiac death during the first 30 days after presentation.

Results:

A total of 1,370 subjects were enrolled, including 908 in the CCTA group and 462 in the group receiving traditional care. Baseline characteristics were similar in the two groups. Of 640 patients with a negative CCTA examination, none died or had a myocardial infarction within 30 days (0%; 95% confidence interval [CI], 0-0.57). Compared to patients receiving traditional care, patients in the CCTA group had a higher rate of discharge from the emergency department (49.6% vs. 22.7%; difference 26.8% points; 95% confidence interval [CI], 21.4-32.2), a shorter length of stay (median 18.0 hours vs. 24.8 hours; p < 0.001), and a higher rate of detection of coronary disease (9.0% vs. 3.5%; difference 5.6% points; 95% CI, 0-11.2). There was one serious adverse event in each group.

Conclusions:

A CCTA-based strategy for low- to intermediate-risk patients presenting with a possible acute coronary syndrome appears to allow the safe, expedited discharge from the emergency department of many patients who would otherwise be admitted.

Perspective:

This large randomized study demonstrated that there were fewer hospitalizations and shorter lengths of stay when CCTA was routinely used among low- to intermediate-risk patients presenting with possible acute coronary syndrome. Many patients in the ‘traditional’ treatment group underwent stress testing, but so did some (albeit fewer) in the CCTA arm—presumably to assess the functional significance of abnormalities noted on CCTA. Although revascularization rates were low in both groups, they were higher among patients who underwent CCTA; it is open to question whether revascularization lowered any present or future risk. The long-term risks of radiation exposure with CCTA were not assessed in this short-term study. CCTA might provide an expedient means for disposition of low- to intermediate-risk patients with chest pain, but there still might be a role for good clinical judgment and selective testing.

Clinical Topics: Acute Coronary Syndromes

Keywords: Myocardial Infarction, Acute Coronary Syndrome, Chest Pain, Coronary Disease, Emergency Service, Hospital, Confidence Intervals, Hospitalization, United States


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