The purpose of this study was to compare the efficiency, cost, and safety of a diagnostic strategy employing early coronary computed tomographic angiography (CCTA) to a strategy employing rest-stress myocardial perfusion imaging (MPI) in the evaluation of acute low-risk chest pain.
In the United States, >8 million patients require emergency department evaluation for acute chest pain annually at an estimated diagnostic cost of >$10 billion.
This multicenter, randomized clinical trial in 16 emergency departments ran between June 2007 and November 2008. Patients were randomly allocated to CCTA (n = 361) or MPI (n = 338) as the index noninvasive test. The primary outcome was time to diagnosis; the secondary outcomes were emergency department costs of care and safety, defined as freedom from major adverse cardiac events in patients with normal index tests, including 6-month follow-up.
The CCTA resulted in a 54% reduction in time to diagnosis compared with MPI (median 2.9 h [25th to 75th percentile: 2.1 to 4.0 h] vs. 6.3 h [25th to 75th percentile: 4.2 to 19.0 h], p < 0.0001). Costs of care were 38% lower compared with standard (median $2,137 [25th to 75th percentile: $1,660 to $3,077] vs. $3,458 [25th to 75th percentile: $2,900 to $4,297], p < 0.0001). The diagnostic strategies had no difference in major adverse cardiac events after normal index testing (0.8% in the CCTA arm vs. 0.4% in the MPI arm, p = 0.29).
In emergency department acute, low-risk chest pain patients, the use of CCTA results in more rapid and cost-efficient safe diagnosis than rest-stress MPI. Further studies comparing CCTA to other diagnostic strategies are needed to optimize evaluation of specific patient subsets. (Coronary Computed Tomographic Angiography for Systematic Triage of Acute Chest Pain Patients to Treatment [CT-STAT]; NCT00468325).
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"In an outpatient population, CCTA has emerged as an accurate and rapid tool for the exclusion of coronary artery disease     . Recent randomized controlled trials in acute ED patients that compared CCTA to nuclear SPECT , or to a mixed standard-of-care   showed Table 2 Diagnostic performance for CCTA and exercise ECG-based care. "
[Show abstract][Hide abstract] ABSTRACT: Background
Coronary CT angiography (CCTA) has high sensitivity, with 3 recent randomized trials favorably comparing CCTA to standard-of-care. Comparison to exercise stress ECG (ExECG), the most available and least expensive standard-of-care worldwide, has not been systematically tested.
CT-COMPARE was a randomized, single-center trial of low-intermediate risk chest pain subjects undergoing CCTA or ExECG after the first negative troponin. From March 2010 to April 2011, 562 patients randomized to either dual-source CCTA (n = 322) or ExECG (n = 240). Primary endpoints were diagnostic performance for ACS, and hospital Cost at 30 days. Secondary endpoints were time-to-discharge, admission rates, downstream resource utilization.
ACS occurred in 24 (4%) patients. ExECG had 213 negative studies and 27 (26%) positive studies for ACS with sensitivity 83% [95% CI 36, 99.6%], specificity 91% [CI 86, 94%], ROC AUC 0.87 [CI 0.70,1]. CCTA (> 50% stenosis considered positive) had 288 negative studies and 18/35 (51%) positive studies with a sensitivity 100% [CI 81.5, 100], specificity 94% [CI 91.2,96.7%], ROC 0.97 [CI 0.92,1.0; p = 0.2]. Despite CCTA having higher odds of downstream testing (OR 2.0), 30 day per-patient cost was significantly lower for CCTA ($2193 vs $2704, P < 0.001). Length of stay for CCTA was significantly reduced (13.5 hours [95%CI 11.2-15.7], ExECG 19.7 hours [95%CI 17.4-22.1], p < 0.0005), which drove the reduction in cost. No patient had post-discharge cardiovascular events at 30 days.
CCTA had improved diagnostic performance compared to ExECG, combined with 35% relative reduction in length-of-stay, and 20% reduction in hospital costs. These data lend further evidence that CCTA is useful as a first line assessment in emergency department chest pain.
International Journal of Cardiology 10/2014; 177(3). DOI:10.1016/j.ijcard.2014.10.090 · 4.04 Impact Factor
"There was no significant difference in number of major adverse cardiac events between the two groups. The costs of both tests are very similar, while the exposure to radiation is significantly lower with CCTA.20 "
[Show abstract][Hide abstract] ABSTRACT: Perioperative cardiac events can be a major consequence of surgery. The American College of Cardiology Foundation/American Heart Association has set out guidelines to aid physicians in identifying patients at the highest risk for these events. The guidelines do recommend for some patients to undergo non-invasive cardiac stress testing for further risk stratification, but their sensitivity and specificity for predicting cardiac events is not optimal. With more data emerging of the superior performance of computed coronary tomography angiography (CCTA) compared to non-invasive stress testing, CCTA could be more useful in risk stratification for these patients.
Heart International 01/2013; 8(1):e1. DOI:10.4081/hi.2013.e1
"Moreover , we investigated economic aspects of cCTA in addition to a SOC algorithm for the work-up of acute chest pain in a European country with a DRG system. In the recently published Coronary Computed Tomographic Angiography for Systematic Triage of Acute Chest Pain Patients to Treatment CT-STAT U.S. multi-center trial, low risk patients were randomly allocated to cCTA or myocardial perfusion imaging as the index noninvasive test . Study endpoints were time to diagnosis, emergency department costs of care and safety. "
[Show abstract][Hide abstract] ABSTRACT: Objective:
To evaluate the economic impact of integrating coronary CT angiography (cCTA) or whole chest "triple-rule-out" CTA (TRO-CTA) in the work-up of patients with acute chest pain.
Materials and methods:
100 consecutive emergency department patients with acute chest pain and an intermediate cardiac risk for ACS underwent cCTA or TRO-CTA (cCTA group). Diagnostic performance, rate and length of hospitalization, hospital costs, hospital reimbursement and hospital profit were analyzed. All findings were compared to those of 100 different patients with acute chest pain that were evaluated with a standard of care (SOC) diagnostic algorithm (SOC group) that did not include cCTA. Diagnostic performance ("safety") of both algorithms was defined as the absence of major adverse cardiac events (MACE) over a 90-day follow-up period.
In the cCTA group 60/100 patients were safely discharged at the same day. 19/100 patients were hospitalized due to significant coronary stenosis on cCTA, which was confirmed by invasive coronary catheterization (ICC) in 17/19 patients. Relevant non-coronary disease that led to hospitalization were found in 21 patients of the cCTA group. In the SOC group all patients were hospitalized. 87 of these hospitalized patients underwent ICC for exclusion of coronary artery stenosis. A significant coronary artery stenosis was found in only 25 of these patients. Within the cCTA group no patient suffered from MACE over the 90-day follow-up period. In the SOC group 2 patients were rehospitalized during the 90-day follow-up period due to recurrent chest pain and 1 patient because of a pseudoaneurym of the left femoral artery after ICC. The median hospital costs per patient were significantly lower in the cCTA group than in the SOC group (428.9€ vs. 1575.0€, p<0.001). The median reimbursement of the cCTA group was less compared to the SOC group (589.8€ vs. 2412.1€, p<0.001) and patients in the cCTA group gained less profit than patients in the SOC group (57.0€ vs. 448.4€, p<0.001).
Integrating cCTA or TRO-CTA in a SOC algorithm can safely reduce the number of hospitalized patients and reduce total health care costs.
European journal of radiology 07/2012; 82(1). DOI:10.1016/j.ejrad.2012.06.012 · 2.37 Impact Factor