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Coronary Computed Tomography Angiography Versus Stress Echocardiography in Acute Chest Pain: A Randomized Controlled
Jeffrey M Levsky1, Linda B Haramati2, Daniel M Spevack3
1Department of Radiology, Division of Cardiothoracic Imaging, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York; Department of Internal Medicine, Division of Cardiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York.
Objectives:
This study sought to compare early emergency department (ED) use of coronary computed tomography angiography (CTA) and stress echocardiography (SE) head-to-head.
Background:
Coronary CTA has been promoted as the early ED chest pain triage imaging method of choice, whereas SE is often overlooked in this setting and involves no ionizing radiation.
Methods:
The authors randomized 400 consecutive low- to intermediate-risk ED acute chest pain patients without known coronary artery disease and a negative initial serum troponin level to immediate coronary CTA (n = 201) or SE (n = 199). The primary endpoint was hospitalization rate. Secondary endpoints were ED and hospital length of stay. Safety endpoints included cardiovascular events and radiation exposure.
Results:
Mean patient age was 55 years, with 43% women and predominantly ethnic minorities (46% Hispanics, 32% African Americans). Thirty-nine coronary CTA patients (19%) and 22 SE patients (11%) were hospitalized at presentation (difference 8%; 95% confidence interval: 1% to 15%; p = 0.026). Median ED length of stay for discharged patients was 5.4 h (interquartile range [IQR]: 4.2 to 6.4 h) for coronary CTA and 4.7 h (IQR: 3.5 to 6.0 h) for SE (p < 0.001). Median hospital length of stay was 58 h (IQR: 50 to 102 h) for coronary CTA and 34 h (IQR: 31 to 54 h) for SE (p = 0.002). There were 11 and 7 major adverse cardiovascular events for coronary CTA and SE, respectively (p = 0.47), over a median 24 months of follow-up. Median/mean complete initial work-up radiation exposure was 6.5/7.7 mSv for coronary CTA and 0/0.96 mSv for SE (p < 0.001).
Conclusions:
The use of SE resulted in the hospitalization of a smaller proportion of patients with a shorter length of stay than coronary CTA and was safe. SE should be considered an appropriate option for ED chest pain triage (Stress Echocardiography and Heart Computed Tomography [CT] Scan in Emergency Department Patients With Chest Pain; NCT01384448).
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