Safety and Simplicity in the Management of Chest Pain: A New Role for CT Angiography?

What is the most cost-effective approach to ruling out an acute coronary syndrome in a patient who presents with chest pain?

Primary care patients with chest pain comprise a sizeable cohort. Not only do some have a potentially fatal disease (an acute coronary syndrome), but those who do not (most of them, or 85% to 90% of the visits) are often admitted from the emergency department and add needless costs. These patients may undergo unnecessary coronary angiography with attendant risks.

A recent “Top Paper” attempted to identify those low-to-intermediate risk patients who could be safely discharged from the emergency department.¹ The
decision relies on coronary computed tomographic angiography (CCTA), which has a very high negative predictive value for the detection of coronary artery disease.

BENEFITS OF CT ANGIOGRAPHY IN THE Emergency department

Five emergency department sites were utilized. Patients 30 years of age or older were eligible if the treating physician decided that they would require admission and/or further testing to identify an acute coronary syndrome. In addition, these patients had an ECG without signs of acute ischemia and a Thrombolysis in Myocardial Infarction Risk Score of 0 to 2 (identifying them as low-to-intermediate risk). Randomization was performed in a 2:1 ratio, that is, 2 to CCTA for every 1 randomized to traditional management (admission with further decisions, such stress testing or angiography, to follow).

The results were encouraging: 1370 subjects were enrolled, 908 for CCTA and 462 who were managed without. Six hundred forty patients had a negative CCTA, and none died or experienced a myocardial infarction on 30-day follow-up. Approximately 49% of the CCTA group were discharged from the emergency department; only 22.7% of the traditional group were. The CCTA patients also had a shorter length of stay and a higher detection of coronary disease (9.0% versus 3.5%). Another important finding was that the traditional group underwent more negative angiograms. These may lead to complications (bleeding or acute renal insufficiency, for example).

POTENTIAL COST SAVINGS

Acute chest pain syndromes are the second most common reason for emergency department visits in the United States.¹ The number of visits has reached approximately 6 million per year. The cost for the traditional approach exceeds $3 billion dollars a year. Although the CCTA strategy is limited to low- and intermediate-risk patients and exposes these patients to radiation, the strategy utilized in this study appears to be safe and has the potential of providing a significant cost savings to the US healthcare system.