Coronary CT Angiography for Suspected ACS
Is coronary CT angiography (CCTA) superior to standard of care (SOC) in the evaluation of patients presenting to the emergency department (ED) with acute chest pain?
The BEACON(Better Evaluation of Acute Chest Pain with Computed Tomography Angiography) multicenter study randomized 500 ED patients with acute chest pain to CCTA versus SOC, and compared the number of patients with significant coronary artery disease (CAD) requiring revascularization within the initial 30 days. Secondary endpoints included length of stay, discharge rate from the ED, undetected acute coronary syndrome (ACS), medical costs, and repeat ED visits within 30 days. Both arms included standard assessment by electrocardiography (ECG) and high-sensitivity troponin testing. Exclusion criteria included known coronary artery disease, troponin levels >3 times the upper limit of the 99th percentile, severe obesity, or contraindication to CCTA.
The randomized cohorts were similar with regard to demographics, medications, cardiovascular risk factors, and ED findings. Between the CCTA (n = 250) and SOC (n = 250) cohorts, there were no differences in rates of invasive coronary angiography (17% vs. 13%, p = 0.20), coronary revascularization (9% vs. 7%, p = 0.40), diagnosis of ACS at discharge (9% vs. 7%, p = 0.40), repeat ED visit (5% vs. 8%, p = 0.27), undetected ACS (0% vs. 1%, p = 0.62), major adverse cardiac event (10% vs. 9%, p = 0.54), and all-cause mortality (0% vs. 0%, p = 1.0). There were no differences between CCTA and SOC cohorts regarding length of stay (median 6.3 vs. 6.3 hours, p = 0.80) or discharge from the ED (65% vs. 59%, p = 0.16), but there were differences in the 30-day rate of exercise ECG testing (13% vs. 58%, p < 0.01) and nuclear stress testing (1% vs. 7%, p < 0.01), median cost (€337 vs. €511, p < 0.01), and mean radiation dose (7.3 ± 6.6 mSv vs. 2.6 ± 6.5 mSv).
In patients presenting to the ED with acute chest pain, CCTA did not result in differences in adverse events as compared with SOC. Although CCTA was associated with decreased costs, it was also associated with increased patient radiation exposure.
Consistent with prior studies, these findings suggest that CCTA is a safe option in patients presenting to the ED with acute chest pain. However, putting this study together with prior literature, there is no convincing evidence that CCTA is superior to SOC in this population. Further, CCTA was associated with increased exposure to ionizing radiation, which may result in a very small potential for harm. While almost all patients in the CCTA group underwent a CCTA as part of the study protocol, only two-thirds of patients in the SOC group underwent stress testing. If we assume similar groups, providers may have ordered no test at all in one-third of patients in the CCTA group. It would be interesting to see the findings of this study if the design mandated stress testing or CCTA only when the provider felt it to be clinically warranted, which one would expect to be preferable to protocol-mandated testing.
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