CT scans for chest pain widely performed, rarely valuable

Patients presenting in the emergency department with pronounced chest pain but no other signs of acute coronary syndromes don’t have better outcomes when they’re sent for stress testing or coronary CT angiography (CCTA) on top of gurney-side clinical assessment with blood testing, echocardiogram and so on.

They do, however, end up enduring longer lengths of stay, more downstream testing and greater radiation exposure, along with a bigger bill.

So found researchers at Washington University in St. Louis when they analyzed data on 1,000 randomized patients from nine U.S. hospitals, according to a study published online Nov. 14 in JAMA Internal Medicine.

Samuel Reinhardt, MD, and colleagues found that, of the 1,000 patients, 88 percent received CCTA or stress testing even after their biomarker assessments, ECGs, clinical histories and physical exams all came back negative.

Comparing these patients with those who only received the basic battery, the researchers found no cases of missed acute coronary syndrome and no difference in the rate of major adverse cardiac events in the 28 days following the chest-pain ED visit.

The rates were also close to the same among the two groups for receiving percutaneous coronary intervention and/or coronary artery bypass surgery as well as making return visits to the ED.

There was one blip: More cases of acute coronary syndrome were indeed diagnosed in patients who underwent the additional noninvasive exams. “[O]ur current understanding of the pathophysiologic origins of acute coronary syndrome would suggest that the noninvasive test (CCTA or stress test) itself did not contribute to making that diagnosis,” Reinhardt et al. comment on this finding.

In an accompanying editorial, Gregory Curfman, MD, of Harvard states that the study should prompt a randomized clinical trial to more definitively address the question of whether or not it’s generally appropriate to send chest-pain patients for CCTA and/or stress testing.

The JAMA Network has posted the study in full for free.