Outcomes After Coronary Computed Tomography Angiography in the Emergency Department: A Systematic Review and Meta-Analysis of Randomized, Controlled Trials

Study Questions:

What is the impact of coronary computed tomographic angiography (CCTA) on the management and outcomes of patients presenting to the emergency department (ED) with acute chest pain, as compared to usual care?

Methods:

This meta-analysis examined randomized, controlled clinical trials of patients presenting with acute chest pain to the ED receiving CCTA versus usual care, with at least 1 month of follow-up, and with at least 100 enrolled patients. The final analyses included four randomized clinical trials with a total of 1,869 patients examined by CCTA and 1,397 patients who underwent usual care, and examined outcomes including short-term mortality, myocardial infarction, length of stay, post-discharge ED visits, re-hospitalization, and rates of downstream invasive angiography and revascularization.

Results:

Mean age was 51 ± 9 years; 49% were male. There were no deaths, and data on nonfatal myocardial infarction were not adequate for pooled analysis. The pooled weighted rate of invasive angiography was 8.4% for CCTA versus 6.3% for usual care (p = 0.03), with an absolute increase of 21 procedures per 1,000 CCTA patients. The pooled weighted rate of revascularization was 4.6% for CCTA versus 2.6% for usual care (p = 0.004), with an absolute increase in 20 procedures per 1,000 CCTA patients. Between patients imaged by CCTA versus usual care, there were no differences in pooled weighted repeat ED visits (1.5% vs. 1.3%, p = 0.70) or re-hospitalization for acute coronary syndromes (1.5% vs. 1.3%, p = 0.50). Pooled analyses were not feasible for length of stay or costs, but all four studies demonstrated a significantly decreased length of stay using CCTA, and three of the four studies demonstrated reduced ED costs with CCTA.

Conclusions:

In patients with acute chest pain presenting to the ED, performance of CCTA was associated with reduced length of stay and generally reduced costs, as well as increased rates of invasive angiography and coronary revascularization.

Perspective:

This study finds that while CCTA generally results in lower hospital costs and reduced length of stay, these patients also have increased rates of invasive angiography and revascularization. As the authors acknowledge, it is unclear whether these findings represent overutilization of invasive angiography and revascularization following CCTA, or underutilization following usual care; nevertheless, the burden of proof is on CCTA to demonstrate that this is not a result of overutilization compared to standard care. Further, short-term findings may not reflect long-term outcomes, costs, and resource utilization, and additional studies are needed to address these questions. But perhaps most importantly, overall event rates were low in these populations, suggesting that many of these patients may not need additional testing at all, and may be better suited for outpatient follow-up, rather than protocols that rely on automated imaging tests.

Clinical Topics: Acute Coronary Syndromes, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Interventions and ACS, Interventions and Imaging, Angiography, Nuclear Imaging

Keywords: Acute Coronary Syndrome, Myocardial Infarction, Follow-Up Studies, Costs and Cost Analysis, Length of Stay, Hospital Costs, Outpatients, Coronary Angiography, Chest Pain, Tomography, Resin Cements


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