Sex Differences in the Effectiveness of Early Coronary CT Angiography Compared to Standard Emergency Department Evaluation for Acute Chest Pain: The ROMICAT II Trial
Does early cardiac computed tomographic angiography (CCTA) versus emergency department (ED) evaluation improve evaluation of men and women presenting with acute chest pain?
Data were used from the ROMICAT II (Rule-Out Myocardial Infarction With Computer-Assisted Tomography II) study, a multicenter controlled trial, in which 1,000 patients were randomized from nine centers in the United States (47% women), ages 40-70 years old, to early CCTA or standard ED evaluation. All participants presented with symptoms suggestive of acute coronary syndrome (ACS). The present analysis examined gender differences in specific outcomes including length of stay, hospital admission, and cumulative radiation dose.
A total of 1,000 participants were included in this study; of those in the CCTA arm, 239 were women and 262 were men. There were no differences in the baseline characteristics between the two randomized arms (early CCTA vs. standard ED evaluation). However, overall, women were older, more frequently African American, more often diabetic, and were more likely to be on beta-blocker medications. Women had lower rates of ACS as a final diagnosis compared to men (3% vs. 12%, p < 0.0001). Women randomized to early CCTA had greater reduction in length of stay, lower hospital admission rates, and lesser increased cumulative radiation dose than men when comparing ED strategies (p-interactions ≤ 0.02). Women had lower ACS rates than men (3% vs. 12%, p < 0.0001); however, sex differences in length of stay persisted after adjustment for baseline differences including ACS rate (p interaction < 0.03). Length of stay was similar between sexes with normal CCTA findings (p = 0.11). There was no missed ACS for either sex. No difference was observed in major adverse cardiac events between sex and ED strategies (p-interaction = 0.39). Women had more normal CCTA examinations than men (58% vs. 37%, p < 0.0001), less obstructive coronary disease by CCTA (5% vs. 17%, p = 0.0001), but similar normalcy rates for functional testing (p = 1.0). Men in the CCTA arm had the highest rate of invasive coronary angiography (18%), while women had comparable low 5% rates irrespective of ED strategies.
The investigators concluded that early CCTA as a strategy for evaluating women who present to the ED with symptoms suggestive of ACS is a potential useful strategy, resulting in reduced admissions, length of stay, and radiation dose.
These data suggest that use of CCTA in the ED to evaluate women with ACS type symptoms may be effective. Further study including longer-term follow-up may be useful prior to widespread adoption of this strategy.
Keywords: Fluorodeoxyglucose F18, Coronary Angiography, Chest Pain, Emergency Service, Hospital, Positron-Emission Tomography
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