Outcomes After Coronary Computed Tomography Angiography in the Emergency Department

Hulten, Edward; Pickett, Chris A; Bittencourt, Márcio Sommer; Villines, Todd C.; Petrillo, Sara; Carli, Marcelo F. Di; Blankstein, Ron

doi:10.1016/j.jacc.2012.11.061

Cited by 219 publications

(76 citation statements)

References 42 publications

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“…This was a single-center study but included patients similar to those reported in other multicenter trials comparing SPECT with CTA (3,4). Second, although our event rate was low, it was comparable to other studies evaluating patients with CTA (3.8 vs. 4.4%) (16). Third, most patients were not imaged in the ED but admitted under observational care because neither CTA nor SPECT was available in the evening hours.…”

Section: Cacssupporting

confidence: 60%

Optimizing Evaluation of Patients with Low-to-Intermediate-Risk Acute Chest Pain: A Randomized Study Comparing Stress Myocardial Perfusion Tomography Incorporating Stress-Only Imaging Versus Cardiac CT

et al. 2015

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The purpose of this study was to determine whether stress myocardial perfusion (SPECT) optimized with stress-only (SO) imaging is comparable to cardiac CT angiography (CTA) for evaluating patients with acute chest pain (ACP). Methods: This was a prospective randomized observational study in 598 ACP patients who underwent CTA versus SPECT. The primary endpoint was length of hospital stay, and secondary endpoints were test feasibility, time to diagnosis, diagnostic accuracy, radiation exposure, and overall cost. Median follow-up was 6.5 mo, with a 3.8% cardiac event rate defined as death or an acute coronary syndrome. Results: Of 2,994 patients screened, 1,703 (56.9%) were not candidates for CTA because of prior cardiac disease (41%) or imaging contraindications (16%). Time to diagnosis (8.1 ± 8.5 vs. 9.4 ± 7.4 h) and length of hospital stay (19.7 ± 27.8 vs. 23.5 ± 34.4 h) were significantly shorter with CTA than with SPECT (P 5 0.002). However, time to diagnosis (7.0 ± 6.2 vs. 6.8 ± 5.9 h, P 5 0.20), length of stay (15.5 ± 17.2 vs. 16.7 ± 15.3 h, P 5 0.36), and hospital costs ($4,242 ± $3,871 vs. $4,364 ± 1781, P 5 0.86) were comparable with CTA versus SO SPECT, respectively. SO was also superior to conventional SPECT regarding all of the above metrics and significantly reduced radiation exposure (5.5 ± 4.4 vs. 12.5 ± 2.7 mSv, P , 0.0001). Conclusion: Stress SPECT when optimized with SO imaging is similar to CTA in time to diagnosis, length of hospital stay, and cost, with improved prognostic accuracy and less radiation exposure. Our results emphasize the importance of SO imaging, particularly in low-intermediate-risk emergency room patients who are a population likely to have a normal test result.

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Section: Cacssupporting

confidence: 60%

Optimizing Evaluation of Patients with Low-to-Intermediate-Risk Acute Chest Pain: A Randomized Study Comparing Stress Myocardial Perfusion Tomography Incorporating Stress-Only Imaging Versus Cardiac CT

et al. 2015

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“…[11][12][13] Several recent randomized studies and two metaanalyses have been published examining the diagnostic utility of CTA in evaluating patients in the ED with possible ACS. [14][15][16][17][18][19] Recent CTA studies have suggested efficient triage of patients, safe expedited discharge from the ED, cost effectiveness, and lower radiation dose when compared to standard diagnostic evaluation including MPI. However, this comparison has been to older conventional Na-I SPECT cameras using traditional rest-stress protocols.…”

Section: Introductionmentioning

confidence: 99%

A comparison of coronary CTA and stress testing using high-efficiency SPECT MPI for the evaluation of chest pain in the emergency department

Duvall

Savino

Levine

et al. 2014

Journal of Nuclear Cardiology

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Background. Recent studies have compared CTA to stress testing and MPI using older Na-I SPECT cameras and traditional rest-stress protocols, but are limited by often using optimized CTA protocols but suboptimal MPI methodology. We compared CTA to stress testing with modern SPECT MPI using high-efficiency CZT cameras and stress-first protocols in an ED population.Methods. In a retrospective, non-randomized study, all patients who underwent CTA or stress testing (ETT or Tc-99m sestamibi SPECT MPI) as part of their ED assessment in 2010-2011 driven by ED attending preference and equipment availability were evaluated for their disposition from the ED (admission vs discharge, length of time to disposition), subsequent visits to the ED and diagnostic testing (within 3 months), and radiation exposure. CTA was performed using a 64-slice scanner (GE Lightspeed VCT) and MPI was performed using a CZT SPECT camera (GE Discovery 530c). Data were obtained from prospectively acquired electronic medical records and effective doses were calculated from published conversion factors. A propensity-matched analysis was also used to compare outcomes in the two groups.Results. A total of 1,458 patients underwent testing in the ED with 192 CTAs and 1,266 stress tests (327 ETTs and 939 MPIs). The CTA patients were a lower-risk cohort based on age, risk factors, and known heart disease. A statistically similar proportion of patients was discharged directly from the ED in the stress testing group (82% vs 73%, P 5 .27), but their time to disposition was longer (11.0 ± 5 vs 20.5 ± 7 hours, P < .0001). There was no significant difference in cardiac return visits to the ED (5.7% CTA vs 4.3% stress testing, P 5 .50), but more patients had follow-up studies in the CTA cohort compared to stress testing (14% vs 7%, P 5 .001). The mean effective dose of 12.6 ± 8.6 mSv for the CTA group was higher (P < .0001) than 5.0 ± 4.1 mSv for the stress testing group (ETT and MPI). A propensity score-matched cohort showed similar results to the entire cohort.Conclusions. Stress testing with ETT, high-efficiency SPECT MPI, and stress-only protocols had a significantly lower patient radiation dose and less follow-up diagnostic testing than CTA with similar cardiac return visits. CTA had a shorter time to disposition, but there was a trend toward more revascularization than with stress testing. (J Nucl Cardiol 2014;21:305-18.)

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“…Several studies have focused on the performance of CTA as the first test for chest pain evaluation 5, 6. The largest study on this subject was the PROMISE (The Prospective Multicenter Imaging Study for Evaluation of Chest Pain) trial 7.…”

Section: Introductionmentioning

confidence: 99%

“…Other studies have also associated early CTA use with fewer heart attacks. Both meta‐analysis of stable angina patients5 and meta‐analysis of emergency room patients6 suggested a significantly lower incidence of myocardial infarction in those randomized to early CTA.…”

Section: Introductionmentioning

confidence: 99%

“…The 2013 guidelines have lowered the barrier to statin therapy, and this might further reduce the number of patients in whom early CTA changes medical therapy. The use of CTA as an initial test for chest discomfort is associated with fewer heart attacks per meta‐analysis and this effect might be due to initiation of medical therapy 5, 6. FFRCT appears to offer improved precision of care with use of fewer resources.…”

Section: Introductionmentioning

confidence: 99%

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Improved Precision of Initial Chest Pain Evaluation With Fractional Flow Reserve Computed Tomography

Sigurðsson

2017

JAHA

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Outcomes After Coronary Computed Tomography Angiography in the Emergency Department

Abstract: Compared with UC, the use of CCTA in the ED is associated with decreased ED cost and length of stay but increased ICA and revascularization.

Cited by 219 publications

References 42 publications

Optimizing Evaluation of Patients with Low-to-Intermediate-Risk Acute Chest Pain: A Randomized Study Comparing Stress Myocardial Perfusion Tomography Incorporating Stress-Only Imaging Versus Cardiac CT

Optimizing Evaluation of Patients with Low-to-Intermediate-Risk Acute Chest Pain: A Randomized Study Comparing Stress Myocardial Perfusion Tomography Incorporating Stress-Only Imaging Versus Cardiac CT

A comparison of coronary CTA and stress testing using high-efficiency SPECT MPI for the evaluation of chest pain in the emergency department

Improved Precision of Initial Chest Pain Evaluation With Fractional Flow Reserve Computed Tomography

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