Author + information
A single center, prospective, randomized study was undertaken to evaluate the safety and efficacy of coronary CT angiography (CCTA) guided strategy to triage patients admitted to Emergency Department (ED) with acute chest pain.
206 patients admitted to ED with acute chest pain and low to intermediate risk of ACS were randomized into two groups: Group A: CCTA guided strategy (104 pts, 52 F) and Group B: risk assessment and invasive angiography according to standard practice (102 pts, 55 F). In Group A all patients underwent ECG gated 64slice CCTA appended to routine proceeding.
Among of 1096 coronary segments, 92 (8.3%) were not suitable for evaluation by CCTA (mostly distal segments and small branches). Effective radiation dose for CCTA was 9.4±4.2 mSv. In 74 patients (71%) CCTA excluded significant coronary stenosis as a cause of acute chest pain. In this group of patients CCTA revealed lung nodules (n=4), pulmonary embolism (n=5), enlarged mediastinal lymph nodes (n=17) and esophageal hernia (n=4) as other possible causes of acute chest pain. Invasive coronary angiography was performed in 30 patients (29%) in group A and in 98 patients (94%) in group B (p<0,002). Revascularization followed invasive angiography in 28 patients (93%) in group A and in 36 patients (37%) in group B. Mean time of hospital stay was significantly shorter in group A (55±21 hrs vs. 90±34 hrs, p<0,005). There were no undetected acute coronary syndromes and no significant differences in major adverse cardiovascular events at 1 year. CCTA demonstrated very high discriminative value for selecting patients requiring invasive angiography: area under ROC curve 0.977 (0.95 confidence interval, p<0.002, sensitivity 100%, Specificity 95.4% PPV 89%, NPV 100%.
In patients in the emergency department with acute chest pain and low to intermediate risk of acute coronary syndromes, incorporating CCTA guided strategy to triage patients for invasive or conservative treatment decreases the number of invasive angiographies, shortened time of hospital stay and allowed the diagnosis of other, noncardiac causes of acute chest pain with excellent long term outcome in comparison to standard strategy.