Document Detail


Coronary CT angiography versus standard evaluation in acute chest pain.
MedLine Citation:
PMID:  22830462     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
BACKGROUND: It is unclear whether an evaluation incorporating coronary computed tomographic angiography (CCTA) is more effective than standard evaluation in the emergency department in patients with symptoms suggestive of acute coronary syndromes.
METHODS: In this multicenter trial, we randomly assigned patients 40 to 74 years of age with symptoms suggestive of acute coronary syndromes but without ischemic electrocardiographic changes or an initial positive troponin test to early CCTA or to standard evaluation in the emergency department on weekdays during daylight hours between April 2010 and January 2012. The primary end point was length of stay in the hospital. Secondary end points included rates of discharge from the emergency department, major adverse cardiovascular events at 28 days, and cumulative costs. Safety end points were undetected acute coronary syndromes.
RESULTS: The rate of acute coronary syndromes among 1000 patients with a mean (±SD) age of 54±8 years (47% women) was 8%. After early CCTA, as compared with standard evaluation, the mean length of stay in the hospital was reduced by 7.6 hours (P<0.001) and more patients were discharged directly from the emergency department (47% vs. 12%, P<0.001). There were no undetected acute coronary syndromes and no significant differences in major adverse cardiovascular events at 28 days. After CCTA, there was more downstream testing and higher radiation exposure. The cumulative mean cost of care was similar in the CCTA group and the standard-evaluation group ($4,289 and $4,060, respectively; P=0.65).
CONCLUSIONS: In patients in the emergency department with symptoms suggestive of acute coronary syndromes, incorporating CCTA into a triage strategy improved the efficiency of clinical decision making, as compared with a standard evaluation in the emergency department, but it resulted in an increase in downstream testing and radiation exposure with no decrease in the overall costs of care. (Funded by the National Heart, Lung, and Blood Institute; ROMICAT-II ClinicalTrials.gov number, NCT01084239.).
Authors:
Udo Hoffmann; Quynh A Truong; David A Schoenfeld; Eric T Chou; Pamela K Woodard; John T Nagurney; J Hector Pope; Thomas H Hauser; Charles S White; Scott G Weiner; Shant Kalanjian; Michael E Mullins; Issam Mikati; W Frank Peacock; Pearl Zakroysky; Douglas Hayden; Alexander Goehler; Hang Lee; G Scott Gazelle; Stephen D Wiviott; Jerome L Fleg; James E Udelson;
Publication Detail:
Type:  Comparative Study; Journal Article; Multicenter Study; Randomized Controlled Trial; Research Support, N.I.H., Extramural    
Journal Detail:
Title:  The New England journal of medicine     Volume:  367     ISSN:  1533-4406     ISO Abbreviation:  N. Engl. J. Med.     Publication Date:  2012 Jul 
Date Detail:
Created Date:  2012-07-26     Completed Date:  2012-08-02     Revised Date:  2013-08-28    
Medline Journal Info:
Nlm Unique ID:  0255562     Medline TA:  N Engl J Med     Country:  United States    
Other Details:
Languages:  eng     Pagination:  299-308     Citation Subset:  AIM; IM    
Affiliation:
Department of Radiology, Massachusetts General Hospital, Boston, MA 02114, USA. uhoffmann@partners.org
Data Bank Information
Bank Name/Acc. No.:
ClinicalTrials.gov/NCT01084239
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MeSH Terms
Descriptor/Qualifier:
Acute Coronary Syndrome / complications,  diagnosis*,  radiography
Adult
Aged
Chest Pain / etiology,  radiography*
Coronary Angiography
Electroencephalography
Emergency Service, Hospital
Female
Health Care Costs
Health Resources / utilization
Humans
Length of Stay
Male
Middle Aged
Tomography, X-Ray Computed*
Grant Support
ID/Acronym/Agency:
K23 HL098370/HL/NHLBI NIH HHS; K23HL098370/HL/NHLBI NIH HHS; K24 HL113128/HL/NHLBI NIH HHS; L30HL093896/HL/NHLBI NIH HHS; U01 HL092022/HL/NHLBI NIH HHS; U01 HL092040/HL/NHLBI NIH HHS; U01HL092022/HL/NHLBI NIH HHS; U01HL092040/HL/NHLBI NIH HHS; UL1 RR025758/RR/NCRR NIH HHS; UL1RR025758/RR/NCRR NIH HHS
Comments/Corrections
Comment In:
N Engl J Med. 2012 Jul 26;367(4):375-6   [PMID:  22830468 ]
Evid Based Med. 2013 Aug;18(4):146-7   [PMID:  23213118 ]
N Engl J Med. 2012 Oct 25;367(17):1664-5; author reply 1666   [PMID:  23094736 ]

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