Background It is unclear whether an evaluation incorporating coronary computed tomographic angiography (CCTA) is more effective than standard evaluation in the emergency department in patients with symptoms suggestive of acute coronary syndromes. Methods In this multicenter trial, we randomly assigned patients 40 to 74 years of age with symptoms suggestive of acute coronary syndromes but without ischemic electrocardiographic changes or an initial positive troponin test to early CCTA or to standard evaluation in the emergency department on weekdays during daylight hours between April 2010 and January 2012. The primary end point was length of stay in the hospital. Secondary end points included rates of discharge from the emergency department, major adverse cardiovascular events at 28 days, and cumulative costs. Safety end points were undetected acute coronary syndromes. Results The rate of acute coronary syndromes among 1000 patients with a mean (±SD) age of 54±8 years (47% women) was 8%. After early CCTA, as compared with standard evaluation, the mean length of stay in the hospital was reduced by 7.6 hours (P<0.001) and more patients were discharged directly from the emergency department (47% vs. 12%, P<0.001). There were no undetected acute coronary syndromes and no significant differences in major adverse cardiovascular events at 28 days. After CCTA, there was more downstream testing and higher radiation exposure. The cumulative mean cost of care was similar in the CCTA group and the standard-evaluation group ($4,289 and $4,060, respectively; P=0.65). Conclusions In patients in the emergency department with symptoms suggestive of acute coronary syndromes, incorporating CCTA into a triage strategy improved the efficiency of clinical decision making, as compared with a standard evaluation in the emergency department, but it resulted in an increase in downstream testing and radiation exposure with no decrease in the overall costs of care. (Funded by the National Heart, Lung, and Blood Institute; ROMICAT-II ClinicalTrials.gov number, NCT01084239.)

Background Professional guidelines have reduced the recommended minimum number to an average of 50 PCI procedures performed annually by each operator. Operator volume patterns and associated outcomes since this change are unknown. Objectives To describe PCI operator procedure volumes; characteristics of low-, intermediate-, and high-volume operators; and the relationship between operator volume and clinical outcomes in a large, contemporary, nationwide sample Methods Using data from the nationally representative NCDR CathPCI registry collected between July 1, 2009 and March 31, 2015, we examined operator annual PCI volume. We divided operators into low- (< 50 PCIs/year), intermediate- (50–100 PCIs/year), and high-volume (> 100 PCIs/year) groups, and determined the adjusted association between annual PCI volume and in-hospital outcomes, including mortality. Results The median number of annual procedures performed per operator was 59 (25th, 75th percentiles: 21, 106); 44% of operators performed < 50 PCI procedures/year. Low-volume operators more frequently performed emergency and primary PCI procedures and practiced at hospitals with lower annual PCI volumes. Unadjusted in-hospital mortality was 1.86% for low-volume operators, 1.73% for intermediate-volume operators, and 1.53% for high-volume operators. The adjusted risk of in-hospital mortality was higher for PCI procedures performed by low- and intermediate-volume operators compared with those performed by high-volume operators (adjusted OR 1.16, 95% CI 1.12–1.21 for low vs. high; adjusted OR 1.05, 95% CI 1.02–1.09 for intermediate vs. high volume) as was the risk for new dialysis post PCI. No volume relationship was seen for post-PCI bleeding. Conclusions Many PCI operators in the U.S. are performing fewer than the recommended number of PCI procedures annually. Though absolute risk differences are small and may be partially explained by unmeasured differences in case mix between operators, there remains an inverse relationship between PCI operator volume and in-hospital mortality that persisted in risk-adjusted analyses.

clinicaltrials.gov Identifier: NCT01825798.

African American individuals were less likely to receive guideline-recommended statin therapy. Demographic, clinical, socioeconomic, belief-related, and clinician differences contributed to observed differences and represent potential targets for intervention.