CT angiography for safe discharge of patients with possible acute coronary syndromes
Harold I Litt1, Constantine Gatsonis, Brad Snyder
1Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA. harold.litt@uphs.upenn.edu
Insights
Coronary computed tomographic angiography (CCTA) safely expedites emergency department discharge for low-to-intermediate-risk acute coronary syndrome patients. This diagnostic imaging strategy avoids unnecessary hospital admissions, improving patient flow and reducing healthcare costs.
Area of Science:
- Cardiology
- Emergency Medicine
- Radiology
Background:
- Emergency departments frequently admit patients with symptoms suggestive of acute coronary syndromes (ACS).
- A significant proportion of these patients do not have cardiac causes for their symptoms.
- Coronary computed tomographic angiography (CCTA) shows high accuracy in ruling out coronary artery disease, but its role in safe emergency department discharge is not fully established.
Purpose of the Study:
- To evaluate the safety and efficacy of a CCTA-based strategy for managing low-to-intermediate-risk patients presenting with possible ACS.
- To determine if CCTA can facilitate safe and expedited discharge from the emergency department.
Main Methods:
- A randomized controlled trial involving 1370 low-to-intermediate-risk patients with possible ACS.
- Patients were assigned in a 2:1 ratio to undergo CCTA or receive traditional care.
- The primary safety outcome was the absence of myocardial infarction and cardiac death within 30 days in patients with a negative CCTA.
Main Results:
- In the CCTA group, 908 patients were enrolled; in the traditional care group, 462 patients were enrolled.
- Among 640 patients with a negative CCTA, there were no instances of myocardial infarction or cardiac death within 30 days.
- The CCTA group experienced higher emergency department discharge rates (49.6% vs. 22.7%) and shorter lengths of stay (18.0 hours vs. 24.8 hours) compared to the traditional care group.
Conclusions:
- A CCTA-based strategy enables the safe and rapid discharge of many low-to-intermediate-risk ACS patients from the emergency department.
- This approach can reduce hospital admissions for patients whose symptoms are ultimately non-cardiac.
- CCTA is a valuable tool for risk stratification and management in the emergency department setting for suspected ACS.
Background:
Admission rates among patients presenting to emergency departments with possible acute coronary syndromes are high, although for most of these patients, the symptoms are ultimately found not to have a cardiac cause. Coronary computed tomographic angiography (CCTA) has a very high negative predictive value for the detection of coronary disease, but its usefulness in determining whether discharge of patients from the emergency department is safe is not well established.
Methods:
We randomly assigned low-to-intermediate-risk patients presenting with possible acute coronary syndromes, in a 2:1 ratio, to undergo CCTA or to receive traditional care. Patients were enrolled at five centers in the United States. Patients older than 30 years of age with a Thrombolysis in Myocardial Infarction risk score of 0 to 2 and signs or symptoms warranting admission or testing were eligible. The primary outcome was safety, assessed in the subgroup of patients with a negative CCTA examination, with safety defined as the absence of myocardial infarction and cardiac death during the first 30 days after presentation.
Results:
We enrolled 1370 subjects: 908 in the CCTA group and 462 in the group receiving traditional care. The baseline characteristics were similar in the two groups. Of 640 patients with a negative CCTA examination, none died or had a myocardial infarction within 30 days (0%; 95% confidence interval [CI], 0 to 0.57). As compared with patients receiving traditional care, patients in the CCTA group had a higher rate of discharge from the emergency department (49.6% vs. 22.7%; difference, 26.8 percentage points; 95% CI, 21.4 to 32.2), a shorter length of stay (median, 18.0 hours vs. 24.8 hours; P<0.001), and a higher rate of detection of coronary disease (9.0% vs. 3.5%; difference, 5.6 percentage points; 95% CI, 0 to 11.2). There was one serious adverse event in each group.
Conclusions:
A CCTA-based strategy for low-to-intermediate-risk patients presenting with a possible acute coronary syndrome appears to allow the safe, expedited discharge from the emergency department of many patients who would otherwise be admitted. (Funded by the Commonwealth of Pennsylvania Department of Health and the American College of Radiology Imaging Network Foundation; ClinicalTrials.gov number, NCT00933400.).
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