March 26th, 2012

CT Angiography to Rule Out CAD in Chest-Pain Patients

Each year, 6 million people in the U.S. arrive at the emergency department (ED) with acute chest pain. Although only 10% to 15% of them turn out to have an acute coronary syndrome (ACS), most are admitted to the hospital. Coronary CT angiography (CCTA) has been proposed as a good method to quickly establish the presence or absence of coronary disease and to allow many of these patients to return home sooner.

In a presentation at the ACC and in a simultaneous publication in the New England Journal of Medicine, the ACRIN (American College of Radiology Imaging Network) investigators report the findings of ACRIN PA 4005, the largest trial to date of the strategy to use CCTA to allow for more-rapid ruling out of coronary disease in patients with possible acute coronary syndrome. Investigators randomized 1370 patients with chest pain, in a 2:1 ratio, to either CCTA or conventional care.

The primary outcome was the safety at 30 days of patients with a negative CCTA. Among the 640 patients who had a negative CCTA examination, there were no MIs or cardiac deaths within 30 days.

The investigators also observed that, compared with controls, patients in the CCTA group were more likely to be discharged from the emergency department (49.6% vs. 22.7%) and had a shorter median length of stay (18.0 hours vs. 24.8 hours). Coronary disease was also more likely to be detected in the CCTA group (9.0% versus 3.5%). Utilization of healthcare resources was similar in both groups.

The major drawback to CCTA is radiation, but ACRIN investigator Harold Litt pointed out that the radiation dose received by patients for CCTA is now lower than the dose received during nuclear imaging studies. “We believe that a CCTA-based strategy can safely and efficiently redirect many patients home who would otherwise be admitted,” the authors concluded.

3 Responses to “CT Angiography to Rule Out CAD in Chest-Pain Patients”

  1. Rafael Perez-Mera Perez-Mera, MD says:

    I have no experience with this study, but it is encouraging and should be further investigated,

  2. Matthew Carr, MD says:

    We Have a great deal of experience with the rapid rule out of coronary disease in the ER. My impression is tha we still need to treat these people as patients in pain. Initially, despite neagtive cta (and occasionally negative double and triple rule outs), people still came back to the er with pain at some later date. Since we adopted the protocol of a full consulation, detailed explanation of the results (with pictures to take home) initiation of therpay for alternative diagnoses ( most oftern antacids) and definite follow-up plans as out patients, we have had almost no returns to the er with the same complaint. The coronary cta is part of a human interaction and the best results will not be gotten with the terse phrase “Your tests are negative. Go home”

  3. Hamdy Abdalla, md says:

    and also used as a risk factor in patient with negative test with high calcium score .