Background

Chest Pain due to ACS is one of the

most common presentations to ER

Current strategies to R/O ACS are

inefficient – Unnecessary admissions

and ER overcrowded

Despite low threshold to admit patients

up to 2% of patients Discharged with

missed ACS

Cardiac CT Angiography

Previous studies Showed that CCTA has

Accurate Noninvasive Detection of

significant CAD with High NPV during

the index hospitalization and the

occurrence of major adverse

cardiovascular events over the next 2

years

Hollander JE, Chang AM, Shofer FS, et al. One-year outcomes following coronary computerized tomographic angiography for evaluation of

emergency department patients with potential acute coronary syndrome. Acad Emerg Med 2009;16:693-8

Schlett CL,, et al.

Prognostic value of CT angiography for major adverse cardiac events in patients with acute chest pain from the emergency department: 2-year

outcomes of the ROMICAT trial. JACC Cardiovasc Imaging 2011;4:481-91

The hypothesis

An evaluation strategy incorporating

early CCTA will improve the

effectiveness of clinical decision making

as compared to a Standard ED

Evaluation in Patients with acute chest

pain suggestive of ACS

Study Type : Diagnostic cohort

Study Design : RCT

40 to 74 years of age with symptoms

suggestive of ACS but without ischemic

ECG Changes or an initial positive

troponin test

CCTA

Standard Evaluation

Primary End Point, length of stay in the

hospital

P

I

C

O

Secondary Endpoints Rates of direct discharge from the ED

Cumulative costs

Cumulative radiation exposure

Time to diagnosis

Safety variables (Periprocedural

complications, undetected acute coronary

syndrome within 72 hrs after discharge,

MACE at 28 days)

Utilization of other diagnostic testing

Resource utilization

Inclusion Criteria

Patients with > 5 min of Chest Pain or Angina Equivelant within the past 24 hours

40 to 74 years of age

sinus rhythm Patients

Patient must be able to Hold Breath >10 seconds

Patient must be able to sign an informed consent

Exclusion Criteria

History of known coronary artery disease !!

New diagnostic ischemic changes on the initial ECG

Initial troponin level in excess of the 99th percentile of the local assay

Impaired renal function

Hemodynamic or clinical instability,

Known allergy to an iodinated contrast agent

Body Mass Index greater than 40

Currently symptomatic asthma.

Was the assignment of

patients to treatments

randomized? Yes, randomly assigned in a 1:1 ratio

Was the randomization

Concealed ?

No

Were the groups similar at

the start of the trial?

Yes

Aside from the allocated

treatment were groups treated

equally? Yes, and both arms were Followed up for 28

Days

Were all patients who entered

the trial accounted for?

No, Almost 1% lost the Follow up

Were Patients analysed in the

groups to which they were

randomized? Yes, with the use of intention to treat analysis

Were measures objective

? Yes, they were objectives (Length of

stay and cost and Radiation Exposure)

Were the patients and

clinicians kept “blind” to

which treatment was being

received? No, it wasn’t Blind

Results

Summary

CCTA has:

High Diagnostic Accuracy

Less Time to Dx

More Direct Discharge From ER

Reduce Length of stay

More cost !!

More Radiation

Will the results help me in

caring for my patient?

Yes, But to a limited group of patients

Applicability of the study

Patients were recruited at weekday daytime hours

Patients with History of

Known coronary artery disease

Hemodynamic or clinical instability

Impaired renal function

Limited age group

were excluded

We can Apply CCTA in our institution