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
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.
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
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.
• 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)
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.
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.
2013 Long term outcome and
Outcomes after coronary computed tomography angiography in the emergency department. E Hulten, et al. JACC 2013.
• 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
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.
Special thanks: ROMICAT II and ACRIN-PA breakdown by Salim Rezaie of rebelem.com