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J Am Coll Cardiol. 2016 Jan 5;67(1):16-26. doi: 10.1016/j.jacc.2015.10.045.

Coronary CT Angiography for Suspected ACS in the Era of High-Sensitivity Troponins: Randomized Multicenter Study.

Author information

1
Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Radiology, Erasmus University Medical Center, Rotterdam, the Netherlands. Electronic address: a.dedic@erasmusmc.nl.
2
Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Radiology, Erasmus University Medical Center, Rotterdam, the Netherlands.
3
Department of Cardiology, Amphia Ziekenhuis, Breda, the Netherlands.
4
Department of Cardiology, Catharina Ziekenhuis, Eindhoven, the Netherlands.
5
Department of Cardiology, Canisius Wilhelmina Ziekenhuis, Nijmegen, the Netherlands.
6
Department of Cardiology, St. Antonius Ziekenhuis, Nieuwegein, the Netherlands.
7
Department of Cardiology, Gelre Ziekenhuis, Apeldoorn, the Netherlands.
8
Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands.
9
Department of Emergency Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands.
10
Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Cardiology, Royal Perth Hospital Campus, University of Western Australia, Perth, Australia.
11
Department of Radiology, Erasmus University Medical Center, Rotterdam, the Netherlands.
12
Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands.

Abstract

BACKGROUND:

It is uncertain whether a diagnostic strategy supplemented by early coronary computed tomography angiography (CCTA) is superior to contemporary standard optimal care (SOC) encompassing high-sensitivity troponin assays (hs-troponins) for patients suspected of acute coronary syndrome (ACS) in the emergency department (ED).

OBJECTIVES:

This study assessed whether a diagnostic strategy supplemented by early CCTA improves clinical effectiveness compared with contemporary SOC.

METHODS:

In a prospective, open-label, multicenter, randomized trial, we enrolled patients presenting with symptoms suggestive of an ACS at the ED of 5 community and 2 university hospitals in the Netherlands. Exclusion criteria included the need for urgent cardiac catheterization and history of ACS or coronary revascularization. The primary endpoint was the number of patients identified with significant coronary artery disease requiring revascularization within 30 days.

RESULTS:

The study population consisted of 500 patients, of whom 236 (47%) were women (mean age 54 ± 10 years). There was no difference in the primary endpoint (22 [9%] patients underwent coronary revascularization within 30 days in the CCTA group and 17 [7%] in the SOC group [p = 0.40]). Discharge from the ED was not more frequent after CCTA (65% vs. 59%, p = 0.16), and length of stay was similar (6.3 h in both groups; p = 0.80). The CCTA group had lower direct medical costs (€337 vs. €511, p < 0.01) and less outpatient testing after the index ED visit (10 [4%] vs. 26 [10%], p < 0.01). There was no difference in incidence of undetected ACS.

CONCLUSIONS:

CCTA, applied early in the work-up of suspected ACS, is safe and associated with less outpatient testing and lower costs. However, in the era of hs-troponins, CCTA does not identify more patients with significant CAD requiring coronary revascularization, shorten hospital stay, or allow for more direct discharge from the ED. (Better Evaluation of Acute Chest Pain with Computed Tomography Angiography [BEACON]; NCT01413282).

KEYWORDS:

chest pain; coronary artery disease; diagnosis; emergency department

PMID:
26764061
DOI:
10.1016/j.jacc.2015.10.045
[Indexed for MEDLINE]
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