CCTA most effective for low-risk acute chest pain patients

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Coronary CT angiography (CCTA) can safely triage low-risk, acute chest pain patients and it remains particularly effective because it reduces the length of stay in a hospital and pain for the patient, according to a presentation this weekend at the Transcatheter Cardiovascular Therapeutics (TCT) conference in Washington, D.C.

James Goldstein, MD, from the division of cardiology at William Beaumont Hospital in Royal Oak, Mich, presented his findings and commentary during the “Cardiovascular Non-Invasive Imaging: CTA, MRI, and Beyond, Part I” session. The title of his talk was “Acute Chest Pain,” and his presentation was based on a study he and his colleagues conducted at William Beaumont Hospital. The findings were published in the February issue of the Journal of the American College of Cardiology ( JACC). 

Goldstein suggested that acute chest pain has reached epidemic proportions, totaling six million hospital visits a year, and produces an estimated diagnostic cost of $10 billion to $12 billion. Out of the six million patients, Goldstein said 25 percent were cases of acute myocardial infarction (MI), 25 percent were cases of variant angina, and 50 percent were non-cardiac related. Goldstein also highlighted how missed MIs account for one in five malpractice awards.

Goldstein focused on the advantages of using CCTA for detecting acute coronary disease: confirmation of coronary artery disease; exclusion of the possibilities of a pulmonary embolism, and aortic dissection; negative predictive value of less than 90 percent; and finally, CCTA is cost-efficient because of its speed of diagnosis.

In contrast, an echocardiogram does not exclude ischemia, according to Goldstein. Also, he said that the chest pain triage is not helpful if pain is resolved. He also presented the limitations of each of the present “rule out” strategies, including the ECG, ETT, pragmatics, and enzyme test, the final of which Goldstein said only detect necrosis.
According to the study, Goldstein and his colleagues examined 200 patients under the age of 70, who had very low risk factors. The research performed an immediate CCTA, despite normal ECG and enzymes.

They found immediate disposition in 75 percent of cases, and 25 percent required stress imaging. The researchers reported in JACC that CCTA reduced the overall length of stay to 3.6 hours, compared to 16.5 hours. They also reported that CCTA reduced costs 15 percent overall, from $1,700 to $1,400.

Goldstein on Saturday told Cardiovascular Business News that the CCTA is “really a great test for healthy middle-aged people who will not have to waste time with follow-up visits. For instance, if you have a test on Friday, you typically have to return on Monday or Tuesday for follow-up testing, which is dangerous, but also especially time-consuming for healthy individuals.”

“However, if you take a group of out-of-shape, at-risk men or women, and run them through the test, there are too many incidentals to be accounted for. But, for the average, healthy person, it is both timing-saving and cost-effective,” Goldstein said.

Daniel Berman, MD, chief of cardiac imaging and nuclear cardiology, who presented immediately after Goldstein, questioned some of Goldstein’s findings and suggested that coronary calcium scoring might be most effective in asymptomatic patients.