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Coronary Computed Tomography Angiography Versus Traditional Care: Comparison of One-Year Outcomes and Resource Use
Judd E Hollander1, Constantine Gatsonis2, Erin M Greco3
1Department of Emergency Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA.
Insights
Coronary CT angiography in emergency departments safely evaluates low- to intermediate-risk chest pain patients without increasing resource use over one year. A negative CT angiography result indicates a very low risk of major adverse cardiac events.
Area of Science:
- Cardiology
- Radiology
- Emergency Medicine
Background:
- Coronary computed tomography (CT) angiography is increasingly used for evaluating patients with chest pain in the emergency department (ED).
- Previous trials suggest efficient evaluation and safe discharge are possible with coronary CT angiography for low- to intermediate-risk patients.
- This study reports 1-year outcomes from a multicenter trial investigating coronary CT angiography's impact on event rates and resource utilization.
Purpose of the Study:
- To evaluate 1-year major adverse cardiac event (MACE) rates and resource use in patients with low- to intermediate-risk chest pain managed with a coronary CT angiography care pathway versus traditional care.
- To assess the safety and efficiency of coronary CT angiography in the emergency department setting.
Main Methods:
- A multicenter, randomized clinical trial involving 1,368 patients with low- to intermediate-risk chest pain presenting to the ED.
- Patients were randomized 2:1 to either a coronary CT angiography pathway or traditional care.
- One-year follow-up included telephone contact and medical record review to ascertain MACE (cardiac death, myocardial infarction) and resource utilization (ED revisits, hospital admissions, cardiac procedures).
Main Results:
- No significant difference in 1-year MACE between the coronary CT angiography arm (1.4%) and traditional care (1.1%).
- Similar rates of ED revisits, hospital admissions, and subsequent cardiac testing between the two groups from hospital discharge through 1 year.
- A negative coronary CT angiography result was associated with a very low MACE rate (0.16%) within 1 year.
Conclusions:
- A coronary CT angiography-based strategy for evaluating low- to intermediate-risk chest pain in the ED does not increase 1-year resource use compared to traditional care.
- A negative coronary CT angiography result is a reliable indicator of low MACE risk within the first year post-testing.
Study Objective:
Three large, multicenter, randomized, clinical trials have shown that coronary computed tomography (CT) angiography allows efficient evaluation and safe discharge of patients with low- to intermediate-risk chest pain who present to the emergency department (ED). We report 1-year event rates and resource use from the American College of Radiology Imaging Network-Pennsylvania 4005 multicenter trial.
Methods:
Patients with low- to intermediate-risk chest pain and presenting to the ED were randomized in a 2:1 ratio to a coronary CT angiography care pathway or traditional care. Subjects were contacted by telephone at least 1 year after ED presentation. Medical record review was performed for all cardiac hospitalizations, procedures and diagnostic tests, and adverse cardiac events. Our main outcome was the composite of cardiac death and myocardial infarction within 1 year. The secondary outcome was resource use.
Results:
One thousand three hundred sixty-eight patients enrolled and 1,285 (94%) had direct participant or proxy contact at 1 year. All others had record review or death index search. From index presentation through 1 year, there was no difference between patients in the coronary CT angiography arm versus traditional care with respect to major adverse cardiac event (1.4% versus 1.1%; difference 0.3%; 95% CI -5.5% to 6.0%). From hospital discharge through 1 year, there was also no difference in ED revisits (36% versus 38%; difference -2.1%; 95% CI -7.9% to 3.7%), hospital admissions (16% versus 17%; difference -0.9%; 95% CI -6.7% to 4.9%), or subsequent cardiac testing (13% versus 13%; difference -0.4%; 95% CI -6.2% to 5.5%). One of 640 subjects with a negative coronary CT angiography result had a major adverse cardiac event within 1 year of presentation (0.16%; 95% CI 0.004% to 0.87%).
Conclusion:
A coronary CT angiography-based strategy for evaluation of patients with low- to intermediate-risk chest pain who present to the ED does not result in increased resource use during 1 year. A negative coronary CT angiography result is associated with a less than 1% major adverse cardiac event rate during the first year after testing.
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