• Emergency Radiology Clinical Trials
• Radiography
• Cardiac Imaging Techniques
• Imaging Modalities
• Prevention & Screening

The use of coronary computed tomography (CCTA) for screening patients that present in emergency departments (EDs) with acute chest pain shortens length of stay (LOS) compared with standard ED evaluation, according to the Rule Out Myocardial Infarction Using Computer–Assisted Tomography II Trial [ROMICAT II; NCT01084239]. ROMICAT II also showed that use of CCTA early into an ED evaluation improved clinical decision–making for ED triage compared with the standard approach. Udo Hoffmann, MD, MPH, Massachusetts General Hospital, Boston, Massachusetts, USA, presented results from the study.

The first prospective, multicenter, randomized, controlled trial to compare CCTA screening with standard ED evaluation for patients with chest pain that is suggestive of acute coronary syndrome (ACS), ROMICAT II randomized 1000 patients at 9 sites in a 1:1 ratio to either CCTA screening or standard care. The hypothesis was that CCTA may enable earlier but safe triage, reducing LOS and hospital admissions compared with standard ED evaluation. The primary endpoint was LOS.

Inclusion criteria included chest pain or equivalent symptoms that were suggestive of ACS; patient age between 40 and 74 years; the ability of the patient to hold their breath for at least 10 seconds; and sinus rhythm. Baseline characteristics were similar between the two groups. The main complaint at presentation was anginal pain or equivalent (88.6% in the CCTA group, n=501; 90.6% in the standard ED evaluation group, n=499).

Average time to diagnosis was 10.4 hours in the CCTA group versus 18.7 hours in the standard ED evaluation group (p=0.0001). At discharge, 8.6% of CCTA patients versus 6.4% of those patients in the standard care group had ACS. Agreement between site and independent adjudication for discharge diagnosis was 96.5% (kappa 0.9). There were no missed diagnoses of ACS in either group.

The mean LOS for all CCTA patients was 23.2±37.0 hours versus 30.8±28.0 hours (p=0.0002) for the standard care group. For those without a final diagnosis of ACS, mean LOS was on average 10 hours shorter for the CCTA group (17.2±24.6 vs 27.2±19.5 hours; p<0.0001; Table 1).

The differences in patient disposition were significant, with direct ED discharge of 46.7% for the CCTA group versus 12.4% for the controls (p<0.001). Observation unit admission was 26.6% in the CCTA group versus 53.7% of controls (p=0.001). The respective figures for admission to the hospital and leaving against medical advice were both lower in the CCTA group—25.4% versus 31.7% and 1.3% versus 2.2%, respectively (both p=0.001).

Major adverse events (death, myocardial infarction, unstable angina, urgent revascularization) within 30 days were similar in both groups (0.4 and 1.0, respectively; p=0.37). There was higher cumulative radiation exposure in the CCTA group (14 mSv vs 5.3 mSv; p<0.0001).

Hospital billing data demonstrated no difference in mean total cost ($4004 vs $3828; p=0.72). However, the CCTA–first approach was associated with reduced mean ED costs of $2053±1076 versus $2532±1346 for the standard evaluation group (p<0.0001) that were partially offset by a higher mean hospital cost ($1950 vs $1297; p=0.17) with CCTA. Of note, use of a CCTA–first approach was associated with an increased use of conventional coronary angiography (12% vs 8%; p=0.04) and a numerically greater number of coronary revascularization procedures (6.4% vs 4.2%; p=0.16).

Overall, ROMICAT II shows that CCTA is feasible in the ED for patients who present with suspected ACS and reduces both LOS and time to diagnosis. There was no significant increase in total cost associated with this approach; however, there was increased radiation exposure. Further studies are necessary to see if the use of CCTA in the ED has an effect on clinical outcomes.

• © 2012 MD Conference Express®