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Faster discharge but more downstream testing with use of CCTA in ED

Clinical Question:
Does coronary computed tomographic angiography improve the efficiency of evaluation of emergency department patients with suspected acute coronary syndrome?

Bottom Line:
Although the use of coronary computed tomographic angiography (CCTA) may lead to faster discharge from the emergency department for patients with low-to-intermediate risk of acute coronary syndrome (ACS) as compared with standard evaluation, this strategy leads to increased subsequent testing and greater radiation exposure without reducing costs. Furthermore, for low-risk patients, one can question whether any diagnostic testing, beyond electrocardiogram and troponin testing, is truly required in the emergency department. (LOE = 1b)

Reference:
Hoffmann U, Truong QA, Schoenfeld DA, et al, for the ROMICAT-II Investigators. Coronary CT angiography versus standard evaluation in acute chest pain. N Engl J Med 2012;367(4):299-308.  [PMID:22830462]

Study Design:
Randomized controlled trial (nonblinded)

Funding:
Government

Allocation:
Concealed

Setting:
Emergency department

Synopsis:
A recent POEM reports that a negative CCTA result allows for safe discharge of emergency department patients with symptoms suggestive of acute coronary syndrome. The current study evaluates the effectiveness of this strategy including factors such as length of stay, cost, resource use, and radiation exposure. Using concealed allocation, the investigators randomized patients aged 40 to 74 years who presented to the emergency department with suspected ACS to a strategy using CCTA (n = 501) or a standard evaluation (n = 499). Patients with a history of coronary artery disease, ischemic changes on electrocardiogram, or elevated troponin levels were excluded. Further work-up beyond the initial strategy was at the treating physician’s discretion. Patients in both groups had similar comorbidities and demographics, with an average age of 54 years. Analysis was by intention to treat. In the CCTA group, the mean length of hospital stay decreased by almost 8 hours (23.2 hours vs 30.8 hours; P < .001; median length of stay = 8.6 hours vs 26.7 hours; P < .001) and patients were more likely to be discharged directly from the emergency department (47% vs 12%; P < .001). Overall, only 8% of the study population had a final diagnosis of ACS. No cases of undetected ACS were identified in either group and there was no difference in major cardiovascular events at 1-month follow-up between the 2 groups. However, as compared with the standard evaluation patients, those who had CCTA underwent more downstream diagnostic testing and had greater radiation exposure. Specifically, patients in the CCTA group were more likely to have 2 or more additional tests, which included the CCTA itself, stress tests, and invasive coronary angiography (23% vs 11%; P < .001). Total costs of care were similar in both groups.

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