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ERCAST


Welcome to ERCast, a focused discussion on the questions, quagmires and known unknowns we face everyday in the emergency department.

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Jan 6, 2015

Should we be CAT scanning hearts in the emergency department?

Scenario: A patient presents to the emergency department with chest pain. EKG and enzymes are OK. Then it's off to get a cardiac CT - coronary arteries look clean and off they go. No admission needed, you see their anatomy right there on the scan and it looks fan-freaking-tastic. With all of the energy and money we spend on chest pain workups, admissions, and lawsuits, why is this a bad idea? There are two camps when it comes to Coronary CT Angiography (CCTA).

Camp one says

  • CCTA can get patients out of the hospital faster with a clear idea of their coronary anatomy
  • A CCTA approach has a similar outcome compared to using just EKG and cardiac enzymes

Camp two says, "Wait a sec, why change what we’re doing if using CCTA doesn’t improve outcome over old school EKG and enzymes. CCTA is expensive, there’s radiation, contrast exposure and, if it doesn’t improve outcome, why should we be doing it?

Judd Hollander, one of the world's experts on CCTA use in the emergency department chest pain workup joins the show to give his point of view.

A History of CCTA in the emergency department

2001 Coronary CT vs stress testing

de Filippi et al. Randomized comparison of a strategy of pre discharge coronary angiography versus exercise testing in low-risk patients in a chest pain unit: In hospital and long-term outcomes. JACC 2001

The Study:

  • 248 patients with non-ischemic EKGs
  • Inclusion criteria: age 20-65, low risk by Goldman algorithm, negative biomarkers over 10 hours from symptom onset, no hx of documented CAD
  • Randomized to CCTA (123) or exercise treadmill test/ETT (125)
  • Greater than 50% coronary stenosis equals a positive CCTA

Results: 

  • 19% of CCTA patients had a positive result (over 50% stenosis) compared to 7% of ETT patients
  • Over the next year, CCTA patients had fewer returns (10% vs 30%) and hospital admissions (3% vs 16%) than negative/non-diagnostic ETT patients
  • CCTA patients had higher satisfaction scores and better understanding
  • Long term follow up: rate of death and MI was ZERO in both the negative CCTA and negative/non-diagnostic ETT group

2012 ACRIN-PA Trial

Litt, Harold I., et al. "CT angiography for safe discharge of patients with possible acute coronary syndromes." New England Journal of Medicine 366.15 (2012): 1393-1403.

The Study:

• 1,370 patients, Age > 30 years

Inclusion criteria: TIMI score of 0–2, EKG without ischemic changes, and negative first set of cardiac biomarkers
Randomized 2 patients to CCTA arm (908 patients) for every 1 patient to standard stress arm (462 patients)

Primary Outcome:

  • MI or Death from CAD at 30 days

Secondary Outcomes:

  • Rate of discharge from ED Length of stay (LOS) in ED
  • Rate of detection of CAD
  • Resource utilization

Results:

  • 640/908 pts (70.5%) who underwent CCTA had coronary stenosis of <50% and none had MI or death due to CAD at 30 days
  • Discharge from ED 49.6% with CCTA vs 22.7% with standard stress arm
  • ED LOS 18 hr in CCTA arm vs 24.8 hr in standard stress arm

Conclusion:

  • CCTA allows early discharge of low to intermediate risk patients presenting to the ED with possible ACS.

2012 ROMICAT II Trial

Hoffmann, Udo, et al. "Coronary CT angiography versus standard evaluation in acute chest pain." New England Journal of Medicine 367.4 (2012): 299-308.

The Study

  • 1,000 patients aged 40-74 with acute chest pain
  • CCTA (501 patients) versus standard evaluation (499 patients)

Primary Outcome:

  • Hospital length of stay

Results:

  • Hospital LOS decreased by 7.6 hr in CCTA group. Rate of discharge from ED 47% in CCTA arm vs 12% in standard evaluation arm.
  • No difference in cardiovascular events at 28 days. Cost was similar between two groups: $4,289 CCTA vs $4,060 in Standard arm

Conclusion:

  • CCTA decreases length of stay without an increase in rate of cardiovascular events.

2012 Two year CCTA follow up

Coronary artery disease progression in patients without significant stenosis on coronary computed tomographic angiography. Chang, et al. American Journal of Emergency Medicine. Nov 2012.

The study: 

  • 32 patients with repeat CCTA imaging. No patient below the 50% threshold exceeded 50% stenosis on follow-up.

2013 Long term outcome and downstream effects
Outcomes after coronary computed tomography angiography in the emergency department. E Hulten, et al. JACC 2013.

The study:

  • Four CCTA versus usual care (UC) studies reviewed

Results:

• No deaths and no difference in MI, repeat ED visits or re-hospitalizations

• All studies showed decreased ED length of stay

• 8.4% of CCTA and 6.3% of UC patients had invasive angiography and 4.6% of CCTA and 2.6% of UC patients underwent re-vascularization

Conclusion:

  • CCTA use in the ED decreased length of stay and cost but increased invasive angiography and re-vascularization.

2013 Pushback against use of CCTA in the emergency department

Radecki, Ryan Patrick. "CT coronary angiography: new risks for low-risk chest pain." Emergency Medicine Journal 30.10 (2013): 856-857.

Conclusion:

  • The three main trials on CCTA fail to show prognostic value over current biomarker based risk stratification strategies and result in multiple harms associated with radiocontrast and radiation exposure.

Special thanks: ROMICAT II and ACRIN-PA breakdown by Salim Rezaie of rebelem.com