CCTA in the ED

Issue: September 2012

Cardiology Today Editorial staff asked a panel of experts their opinion on the ROMICAT II study results and the incorporation of early CCTA evaluation for low-risk patients with chest pain presenting to the ED.

Allen J. Taylor, MD, FACC, FAHA

Recent data add to our knowledge of the efficacy of CCTA for low-risk patients with chest pain in the ED. The results of ROMICAT II were vastly positive. This study resonates with what you see in real life in the ED. In my opinion, CCTA is broadly applicable to well-selected patients; it is an efficient use of care; it leads to a fairly definitive diagnosis in the majority of patients; and it is appealing to ED physicians, patients and clinicians because it is a more rapid way to arrive at a diagnosis in areas where uncertainty is not desired and where speed is desired.

Allen J. Taylor

This paper confirms prior work that essentially showed similar results. ROMICAT II is the third randomized trial to show this great efficiency of care with similar overall net health outcomes. I believe it establishes the groundwork for a class 1A recommendation to make CCTA the preferred mode of evaluation for low-risk patients presenting with chest pain in the ED right now.

Allen J. Taylor, MD, FACC, FAHA, is chief of the cardiology division in the department of medicine at Georgetown University.

Rita F. Redberg, MD

ROMICAT II is an important comparative-effectiveness study of CCTA vs. conventional techniques for ED evaluation of patients with suspected acute coronary syndrome who have normal ECGs and cardiac enzymes. Although the CCTA group was discharged 7.6 hours sooner, on average, they also received approximately three times more radiation, which was not insignificant in either group (13.9 ± 10.4 mSv/patient vs. 4.7 ± 8.4 mSv/patient).

Rita F. Redberg

The pivotal question is whether testing leads to improved outcomes in the ED setting for these low- to intermediate-risk chest pain patients. The overall major adverse cardiac event rate was <1% with no deaths in either group in ROMICAT II, as was also seen in the similarly constructed Litt study (N Engl J Med. 2012;366:1393-1403) and CT-STAT (Goldstein JA. J Am Coll Cardiol. 2012;58:1414-1422). Indeed, 90% of these patients turn out not to have ACS and most do not even have CVD. Thus, it would be both faster and safer to discharge these patients directly from the ED without further diagnostic testing when the clinical evaluation, ECG and enzymes indicate they are not a high-risk group.

The diagnostic testing in the ED, besides delaying discharge, comes with a risk of nephrotoxicity from contrast, radiation exposure and some risk of invasive procedures, depending on the testing used. The first question is not which test to use, in which ROMICAT II is certainly helpful, but is a test needed at all?

Rita F. Redberg, MD, is a Cardiology Today Editorial Board member.

Jeffrey Marshall, MD, FSCAI

It is important to look at these data from the perspective of the ED doctor, which I acknowledge I am not. Today’s EDs are mobbed, and those doctors have to have solid tests and screening tools to be able to find the needle in the haystack, meaning the patient whose chest pain is a MI or unstable. Even in this study, only 8% of patients had significant CAD — found by either CCTA or standard evaluation.

Jeffrey Marshall

ROMICAT II is a well-performed study that provides some interesting insights. The authors point out that the patients in the CCTA arm underwent more tests, but the costs were the same and the time in the hospital was less. There were three times more MIs or need for PCI during follow-up in the standard care arm, suggesting that the CCTA arm was less likely to miss a patient with clinically significant CAD. With such small numbers, this did not reach statistical significance, but every year there are 6 million ED visits for chest pain in the United States and the risk for false-negative work-ups could lead to life-threatening consequences.

There was also an increase in radiation exposure with CCTA. In my opinion, 10 mSv is not something to scoff at, but it is also a lot less radiation exposure than older CCTA studies exposed patients to, and there may be algorithms to make exposure even less in the future. There are several other nuances in this study, such as patients must be in sinus rhythm for the test to work well and the fact that this study was done on ‘weekdays during daylight hour,’ certainly not the only time that these patients present to EDs.

The bottom line is that this test is not for everyone, but it can be useful. This is an important point to continue to research in terms of incorporating early CCTA: How do we find the right patient at the right time for the right reason?

Jeffrey Marshall, MD, FSCAI, is president of the Society for Cardiovascular Angiography and Interventions and is from Northeast Georgia Heart Center.

Michael C. Kontos, MD, FACC, FAHA

CCTA adds to the armamentarium of tools that are useful for evaluating low-risk ED patients with possible myocardial ischemia. It is a very useful tool that can be used to accelerate overall care. However, there are some points that require consideration.

Michael C. Kontos

CCTA may not be useful for every patient because of specific exclusion criteria, including those with significant HF, tachycardia, underlying arrhythmias and renal insufficiency. Probably about one-third of low-risk patients would meet standard exclusion criteria for not being able to undergo imaging.

One advantage, and a possible downside of CCTA, is that it can also pick up other diagnoses in the lung, like unsuspected pneumonia. The downside and a question for the ED physicians is: Who will be responsible for following up on the lung nodules and other diagnoses that may be identified with CCTA?

The ROMICAT II data add to other published literature demonstrating the CCTA can be an effective tool for evaluating low-risk patients, primarily for accelerating and shortening their ED length of stay. In this study, surprisingly, there was no substantial cost savings, which many think would have come from shorter lengths of stay. Protocols for CCTA in low-risk patients conducted thus far are research-based studies, primarily at institutions with substantial experience in CCTA. One wonders if some of the acceleration and shortening of ED length of stay observed in the CCTA study arms was because patients were enrolled in these studies and perhaps given preference for CCTA scanning. Also, many of the studies were done during working hours. Another point is the waiting time for patients who come in at night.

It will be helpful if we can create a consolidated, standardized approach to evaluating low-risk patients that would be safe, effective and also cost effective.

Michael C. Kontos, MD, FACC, FAHA, is medical director of the Coronary Intensive Care Unit, co-director of the Chest Pain Evaluation Center and associate professor of internal medicine (cardiology) at Pauley Heart Center, Virginia Commonwealth University.

David E. Winchester, MD, MS

Every year, chest pain results in millions of visits to EDs. Doctors are challenged to determine which patients can be safely discharged and which require additional testing or continued monitoring. CCTA is a rapid, widely available test with excellent negative predictive value and has been embraced by many ED doctors for these qualities. Some have questioned the utility of CCTA and called for more study of this burgeoning test modality. ROMICAT II is an important next step in demonstrating the potential value of CCTA.

David E. Winchester

This large, randomized comparative effectiveness trial enrolled patients with chest pain, nearly two-thirds of whom had at least two CV risk factors. Few screened patients failed to meet study criteria, although enrollment was limited to daylight hours on weekdays. The follow-up was excellent, over 98% at 28 days. The subjects who underwent CCTA had a 7.6 hour reduction in the mean length of stay and a marked increase in percentage directly discharged from the ED (47% vs. 12% for control). For patients ultimately diagnosed with an ACS, those who underwent CCTA were diagnosed 9 hours sooner than the control group. No significant difference was measured in the cost of the two strategies.

ROMICAT II demonstrates that CCTA is not only rapid, widely-available and accurate, but also speeds time to diagnosis and is effective at reducing hospital admissions and ED length of stay without raising costs.

David E. Winchester, MD, MS, is director of cardiovascular services for the Chest Pain Evaluation Center at the University of Florida and Shands Hospital.

Disclosures:

Drs. Taylor, Redberg, Marshall and Kontos report no relevant financial disclosures. Dr. Winchester reports modest research support from internal UF research funds.