Objectives: The purpose of this study was to compare the efficiency, cost, and safety of a diagnostic strategy employing early coronary computed tomographic angiography (CCTA) to a strategy employing rest-stress myocardial perfusion imaging (MPI) in the evaluation of acute low-risk chest pain. Background: In the United States, >8 million patients require emergency department evaluation for acute chest pain annually at an estimated diagnostic cost of >$10 billion. Methods: This multicenter, randomized clinical trial in 16 emergency departments ran between June 2007 and November 2008. Patients were randomly allocated to CCTA (n = 361) or MPI (n = 338) as the index noninvasive test. The primary outcome was time to diagnosis; the secondary outcomes were emergency department costs of care and safety, defined as freedom from major adverse cardiac events in patients with normal index tests, including 6-month follow-up. Results: The CCTA resulted in a 54% reduction in time to diagnosis compared with MPI (median 2.9 h [25th to 75th percentile: 2.1 to 4.0 h] vs. 6.3 h [25th to 75th percentile: 4.2 to 19.0 h], p < 0.0001). Costs of care were 38% lower compared with standard (median $2,137 [25th to 75th percentile: $1,660 to $3,077] vs. $3,458 [25th to 75th percentile: $2,900 to $4,297], p < 0.0001). The diagnostic strategies had no difference in major adverse cardiac events after normal index testing (0.8% in the CCTA arm vs. 0.4% in the MPI arm, p = 0.29). Conclusions: In emergency department acute, low-risk chest pain patients, the use of CCTA results in more rapid and cost-efficient safe diagnosis than rest-stress MPI. Further studies comparing CCTA to other diagnostic strategies are needed to optimize evaluation of specific patient subsets. (Coronary Computed Tomographic Angiography for Systematic Triage of Acute Chest Pain Patients to Treatment [CT-STAT]; NCT00468325)
Bibliographical noteFunding Information:
This study was funded by a research grant from Bayer Pharmaceuticals . Bayer Pharmaceuticals did not design, conduct, analyze, or interpret this study, nor did it prepare or review this manuscript. Dr. Abidov has served on the Speakers' Bureau of Astellas Pharma and has received grant support from Sarver Heart Center . Drs. Achenbach and Lesser have received research grants and speaker honoraria from Siemens . Dr. O'Neil is on the Speakers' Bureau of Bristol Myers-Squibb and Sanofi-Aventis; and is an unpaid consultant for Heartscape and ZOLL Circulation. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- acute chest pain
- coronary computed tomography
- cost of care
- diagnostic effectiveness
- emergency department