Top

The International Journal of Cardiovascular Imaging

Published in:

01-03-2012 | Original Paper

Immediate computed tomography coronary angiography versus delayed outpatient stress testing for detecting coronary artery disease in emergency department patients with chest pain

Authors: David E. Winchester, Preeti Jois, Steven M. Kraft, David C. Wymer, James A. Hill

Published in: The International Journal of Cardiovascular Imaging | Issue 3/2012

Abstract

Noninvasive testing for coronary artery disease (CAD) is warranted for symptomatic patients with intermediate pretest likelihood of CAD. Accomplishing testing in an emergency department (ED) environment is challenging. We compared two strategies of CAD testing in ED patients: immediate computed tomography coronary angiography (CTCA) versus delayed outpatient stress testing. We conducted a historical control cohort study comparing symptomatic ED patients without an acute coronary syndrome who warranted noninvasive CAD testing. Two cohorts (50 patients each) were defined by CAD testing strategy, immediate CTCA versus delayed stress testing. Outcomes were duration of ED stay, detection of CAD, and 3-month rates of readmission, myocardial infarction, (MI) or death. Median duration of stay was 417.5 minutes (interquartile range [IQR] 359.0–581.0) in the CT cohort and 400.0 minutes (IQR 338.0–471.0) in the control cohort (P = 0.53). CAD was detected in 14 CT cohort patients versus 1 in control (P = 0.0004), due to low follow-up in the control cohort (18 of 50, 36%). Obstructive CAD was diagnosed in 6 CT cohort patients versus 1 in control (P = 0.11). During 3 months of follow-up, four patients in each cohort were reevaluated in the ED for chest pain; no patients suffered MI or death. A strategy of immediate CTCA is superior to a delayed stress testing strategy for detecting CAD in ED patients with chest pain and prompting appropriate referrals for further management. Delayed stress testing was primarily ineffective due to low follow-up. Immediate CTCA can be used safely without altering the ED duration of stay.

Nawar EW, Niska RW, Xu J (2007) National hospital ambulatory medical care survey: 2005 emergency department summary. Advance Data 386:1–32PubMed

Richards D, Meshkat N, Chu J, Eva K, Worster A (2007) Emergency department patient compliance with follow-up for outpatient exercise stress testing: a randomized controlled trial. CJEM 9(6):435–440PubMed

Thomas EJ, Burstin HR, O’Neil AC, Orav EJ, Brennan TA (1996) Patient noncompliance with medical advice after the emergency department visit. Ann Emerg Med 27(1):49–55PubMedCrossRef

Rybicki FJ, Otero HJ, Steigner ML et al (2008) Initial evaluation of coronary images from 320-detector row computed tomography. Int J Cardiovasc Imag 24(5):535–546CrossRef

Steigner ML, Otero HJ, Cai T et al (2009) Narrowing the phase window width in prospectively ECG-gated single heart beat 320-detector row coronary CT angiography. Int J Cardiovasc Imag 25(1):85–90CrossRef

Mowatt G, Cook JA, Hillis GS et al (2008) 64-Slice computed tomography angiography in the diagnosis and assessment of coronary artery disease: systematic review and meta-analysis. Heart 94(11):1386–1393PubMedCrossRef

Budoff MJ, Achenbach S, Blumenthal RS et al (2006) Assessment of coronary artery disease by cardiac computed tomography: a scientific statement from the American Heart Association Committee on Cardiovascular Imaging and Intervention, Council on Cardiovascular Radiology and Intervention, and Committee on Cardiac Imaging, Council on Clinical Cardiology. Circulation 114(16):1761–1791PubMedCrossRef

Taylor AJ, Cerqueira M, Hodgson JM et al (2010) ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR 2010 appropriate use criteria for cardiac computed tomography: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the North American Society for Cardiovascular Imaging, the Society for Cardiovascular Angiography and Interventions, and the Society for Cardiovascular Magnetic Resonance. J Am Coll Cardiol 56(22):1864–1894PubMedCrossRef

Goldstein JA, Gallagher MJ, O’Neill WW, Ross MA, O’Neil BJ, Raff GL (2007) A randomized controlled trial of multi-slice coronary computed tomography for evaluation of acute chest pain. J Am Coll Cardiol 49(8):863–871PubMedCrossRef

10.

Meijboom WB, Meijs MF, Schuijf JD et al (2008) Diagnostic accuracy of 64-slice computed tomography coronary angiography: a prospective, multicenter, multivendor study. J Am Coll Cardiol 52(25):2135–2144PubMedCrossRef

11.

Faul F, Erdfelder E, Lang AG, Buchner A (2007) G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods 39(2):175–191PubMedCrossRef

12.

Ovrehus KA, Jensen JK, Mickley HF et al (2010) Comparison of usefulness of exercise testing versus coronary computed tomographic angiography for evaluation of patients suspected of having coronary artery disease. Am J Cardiol 105(6):773–779PubMedCrossRef

13.

Weustink AC, Mollet NR, Neefjes LA et al (2010) Diagnostic accuracy and clinical utility of noninvasive testing for coronary artery disease. Ann Intern Med 152(10):630–639PubMed

14.

Elhendy A, Schinkel A, Bax JJ, van Domburg RT, Poldermans D (2003) Long-term prognosis after a normal exercise stress Tc-99 m sestamibi SPECT study. J Nucl Cardiol 10(3):261–266PubMedCrossRef

15.

Budoff MJ, Shaw LJ, Liu ST et al (2007) Long-term prognosis associated with coronary calcification: observations from a registry of 25,253 patients. J Am Coll Cardiol 49(18):1860–1870PubMedCrossRef

16.

Nabi F, Chang SM, Pratt CM et al (2010) Coronary artery calcium scoring in the emergency department: identifying which patients with chest pain can be safely discharged home. Ann Emerg Med 56(3):220–229PubMedCrossRef

17.

Hollander JE, Chang AM, Shofer FS et al (2009) One-year outcomes following coronary computerized tomographic angiography for evaluation of emergency department patients with potential acute coronary syndrome. Acad Emerg Med 16(8):693–698PubMedCrossRef

18.

Arad Y, Spadaro LA, Roth M, Newstein D, Guerci AD (2005) Treatment of asymptomatic adults with elevated coronary calcium scores with atorvastatin, vitamin C, and vitamin E: the St. Francis heart study randomized clinical trial. J Am Coll Cardiol 46(1):166–172PubMedCrossRef

19.

Engel KG, Heisler M, Smith DM, Robinson CH, Forman JH, Ubel PA (2009) Patient comprehension of emergency department care and instructions: are patients aware of when they do not understand? Ann Emerg Med 53(4):454–461PubMedCrossRef

20.

Wang NE, Gisondi MA, Golzari M, van der Vlugt TM, Tuuli M (2003) Socioeconomic disparities are negatively associated with pediatric emergency department aftercare compliance. Acad Emerg Med 10(11):1278–1284PubMedCrossRef

21.

Clarke C, Friedman SM, Shi K, Arenovich A, Culligan C (2005) Emergency department discharge instructions comprehension and compliance study. CJEM 7(1):5–11PubMed

22.

Rubinshtein R, Halon DA, Gaspar T et al (2007) Usefulness of 64-slice cardiac computed tomographic angiography for diagnosing acute coronary syndromes and predicting clinical outcome in emergency department patients with chest pain of uncertain origin. Circulation 115(13):1762–1768PubMedCrossRef

23.

Madsen T, Mallin M, Bledsoe J et al (2009) Utility of the emergency department observation unit in ensuring stress testing in low-risk chest pain patients. Crit Pathw Cardiol 8(3):122–124PubMed

24.

Chang SA, Choi SI, Choi EK et al (2008) Usefulness of 64-slice multidetector computed tomography as an initial diagnostic approach in patients with acute chest pain. Am Heart J 156(2):375–383PubMedCrossRef

25.

Hollander JE, Litt HI, Chase M, Brown AM, Kim W, Baxt WG (2007) Computed tomography coronary angiography for rapid disposition of low-risk emergency department patients with chest pain syndromes. Acad Emerg Med 14(2):112–116PubMedCrossRef

26.

Gopal A, Nasir K, Ahmadi N et al (2009) Cardiac computed tomographic angiography in an outpatient setting: an analysis of clinical outcomes over a 40-month period. J Cardiovasc Comput Tomogr 3(2):90–95PubMedCrossRef

27.

Beigel R, Oieru D, Goitein O et al (2009) Usefulness of routine use of multidetector coronary computed tomography in the “fast track” evaluation of patients with acute chest pain. Am J Cardiol 103(11):1481–1486PubMedCrossRef

28.

Laudon DA, Behrenbeck TR, Wood CM et al (2010) Computed tomographic coronary artery calcium assessment for evaluating chest pain in the emergency department: long-term outcome of a prospective blind study. Mayo Clin Proc 85(4):314–322PubMedCrossRef

29.

Hollander JE, Chang AM, Shofer FS, McCusker CM, Baxt WG, Litt HI (2009) Coronary computed tomographic angiography for rapid discharge of low-risk patients with potential acute coronary syndromes. Ann Emerg Med 53(3):295–304PubMedCrossRef

30.

Hoffmann U, Bamberg F, Chae CU et al (2009) Coronary computed tomography angiography for early triage of patients with acute chest pain: the ROMICAT (Rule out myocardial infarction using computer assisted tomography) trial. J Am Coll Cardiol 53(18):1642–1650PubMedCrossRef

Title: Immediate computed tomography coronary angiography versus delayed outpatient stress testing for detecting coronary artery disease in emergency department patients with chest pain
Authors: David E. Winchester
Preeti Jois
Steven M. Kraft
David C. Wymer
James A. Hill
Publication date: 01-03-2012
Publisher: Springer Netherlands
Published in: The International Journal of Cardiovascular Imaging / Issue 3/2012
Print ISSN: 1569-5794
Electronic ISSN: 1875-8312
DOI: https://doi.org/10.1007/s10554-011-9870-x

ACC 2024 Congress Coverage

Year in Review: Heart failure and cardiomyopathies

Heart Failure Video

Watch this official video from ACC.24. Dr. Biykem Bozkurt discuss last year's major advances in heart failure and cardiomyopathies.

Watch now

At a glance: The STEP trials

Springer Medicine

Immediate computed tomography coronary angiography versus delayed outpatient stress testing for detecting coronary artery disease in emergency department patients with chest pain

Abstract

ACC 2024 Congress Coverage

Year in Review: Heart failure and cardiomyopathies

Semaglutide benefits people with type 2 diabetes and obesity-related heart failure

Incentivised to exercise

New intervention for STEMI-related cardiogenic shock

» View more highlights on the ACC 2024 congress hub page

At a glance: The STEP trials

Springer Medicine

Abstract

Please log in to get access to this content

Other articles of this Issue 3/2012

Image quality in obese patients undergoing 256-row computed tomography coronary angiography

Cardiovascular imaging 2011 in the International Journal of Cardiovascular Imaging

Favorable neointimal coverage in everolimus-eluting stent at 9 months after stent implantation: comparison with sirolimus-eluting stent using optical coherence tomography

Prognostic value of coronary computed tomographic angiography in patients with arterial hypertension

Coronary wall MR Imaging in patients with rapid heart rates: a feasibility study of black-blood steady-state free precession (SSFP)

Evaluation of in-stent restenosis in the APPROACH trial (assessment on the prevention of progression by Rosiglitazone on atherosclerosis in diabetes patients with cardiovascular history)

ACC 2024 Congress Coverage

Year in Review: Heart failure and cardiomyopathies

Semaglutide benefits people with type 2 diabetes and obesity-related heart failure

Incentivised to exercise

New intervention for STEMI-related cardiogenic shock

» View more highlights on the ACC 2024 congress hub page