The evaluation of acute chest pain in “low risk” patients has been a longstanding challenge for emergency physicians. The use of serial electrocardiograms (ECGs) and biomarkers to “rule out” myocardial infarction (MI), followed by stress testing or cardiac imaging, has become the standard of care, but is resource-intensive and expensive. This study evaluated coronary computed tomographic angiography (CCTA) as a potential alternative to the current standard of care. The study was conducted as a multicenter comparative effectiveness trial comparing CCTA to rest-stress myocardial perfusion imaging (MPI). Patients with acute chest pain and low risk for MI (defined as Thrombolysis in Myocardial Infarction [TIMI] risk score < 4) with no ECG changes concerning for acute ischemia and no elevated serum biomarkers were randomized to receive CCTA vs. MPI. Patients with CCTA showing < 25% coronary arterial stenoses were eligible for discharge home; patients with 25–70% stenoses were recommended for cross-over for rest-stress MPI, and patients with > 70% stenoses were referred for invasive coronary angiography. Importantly, this study was not powered to compare the diagnostic accuracy of CCTA or MPI, but rather their diagnostic efficiency, or time from randomization to result. The authors found that use of CCTA resulted in a significantly shorter time to diagnosis and decreased total emergency department (ED) costs while maintaining a similar safety profile. The time to diagnosis using CCTA was a median of 2.9 h (25th percentile = 2.1 h, 75th percentile = 4.0 h), compared with 6.2 h (4.2, 19.0) for patients receiving MPI, which was statistically significant. The authors also found a statistically significant reduction in total ED costs in patients undergoing CCTA compared with MPI. There was no significant difference in major adverse cardiac events over a 6-month follow-up between the two groups.
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© 2011 Published by Elsevier Inc.