Article

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

Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA.
New England Journal of Medicine (Impact Factor: 54.42). 03/2012; 366(15):1393-403. DOI: 10.1056/NEJMoa1201163
Source: PubMed

ABSTRACT Admission rates among patients presenting to emergency departments with possible acute coronary syndromes are high, although for most of these patients, the symptoms are ultimately found not to have a cardiac cause. Coronary computed tomographic angiography (CCTA) has a very high negative predictive value for the detection of coronary disease, but its usefulness in determining whether discharge of patients from the emergency department is safe is not well established.
We randomly assigned low-to-intermediate-risk patients presenting with possible acute coronary syndromes, in a 2:1 ratio, to undergo CCTA or to receive traditional care. Patients were enrolled at five centers in the United States. Patients older than 30 years of age with a Thrombolysis in Myocardial Infarction risk score of 0 to 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 examination, with safety defined as the absence of myocardial infarction and cardiac death during the first 30 days after presentation.
We enrolled 1370 subjects: 908 in the CCTA group and 462 in the group receiving traditional care. The 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 to 0.57). As compared with 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 percentage points; 95% CI, 21.4 to 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 percentage points; 95% CI, 0 to 11.2). There was one serious adverse event in each group.
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. (Funded by the Commonwealth of Pennsylvania Department of Health and the American College of Radiology Imaging Network Foundation; ClinicalTrials.gov number, NCT00933400.).

Download full-text

Full-text

Available from: Bradley S. Snyder, Apr 01, 2014
2 Followers
 · 
122 Views
  • 06/2013; 108(5). DOI:10.1007/s00063-013-0260-0
  • [Show abstract] [Hide abstract]
    ABSTRACT: In the United States alone, nearly 7 million patients present annually to emergency departments (ED) with complaints of chest pain suspicious for acute coronary ischemia. Acute chest pain represents a clinical as well as economic challenge, resulting in elaborate, time-consuming, and expensive work-ups to avoid litigation related to missed diagnoses of acute coronary syndromes (ACS). Coronary CT angiography (CTA) is an attractive noninvasive technique with promising data for use in the ED due to its high accuracy and negative predictive value. Recent studies have demonstrated that coronary CTA can aid in safe, rapid, and cost-efficient triage of patients with acute chest pain. Additional applications of plaque characterization, fractional flow analysis, and CT perfusion imaging hold promise in providing incremental data in patients with suspected ACS.
    Current Cardiovascular Imaging Reports 06/2013; 6(3). DOI:10.1007/s12410-013-9196-2
  • [Show abstract] [Hide abstract]
    ABSTRACT: Given the large number of individuals presenting to emergency departments with acute, undifferentiated chest pain and the frequent difficulty in discerning its etiology, there has been great interest in developing techniques that can improve the initial triage of these patients. The ‘Triple Rule Out” CT has recently been touted as a tool to quickly assess for life threatening causes of acute chest pain, namely acute coronary syndrome, pulmonary embolism, and aortic dissection. Initial studies suggest that this protocol is safe and compares favorably with the dedicated CT protocols but at the cost of increased doses of iodinated contrast and radiation. New scanner technology has started to address these limitations but the “Triple Rule Out” CT is still in its infancy. It remains to be seen whether or not this application can ultimately improve diagnostic efficiency, cost, and/or clinical decision making.
    Current Cardiovascular Imaging Reports 10/2012; 5(5). DOI:10.1007/s12410-012-9152-6

Similar Publications