ccta journal club
TRANSCRIPT
Background
Chest Pain due to ACS is one of the
most common presentations to ER
Current strategies to R/O ACS are
inefficient – Unnecessary admissions
and ER overcrowded
Despite low threshold to admit patients
up to 2% of patients Discharged with
missed ACS
Cardiac CT Angiography
Previous studies Showed that CCTA has
Accurate Noninvasive Detection of
significant CAD with High NPV during
the index hospitalization and the
occurrence of major adverse
cardiovascular events over the next 2
years
Hollander JE, Chang AM, Shofer FS, et al. One-year outcomes following coronary computerized tomographic angiography for evaluation of
emergency department patients with potential acute coronary syndrome. Acad Emerg Med 2009;16:693-8
Schlett CL,, et al.
Prognostic value of CT angiography for major adverse cardiac events in patients with acute chest pain from the emergency department: 2-year
outcomes of the ROMICAT trial. JACC Cardiovasc Imaging 2011;4:481-91
The hypothesis
An evaluation strategy incorporating
early CCTA will improve the
effectiveness of clinical decision making
as compared to a Standard ED
Evaluation in Patients with acute chest
pain suggestive of ACS
Study Type : Diagnostic cohort
Study Design : RCT
40 to 74 years of age with symptoms
suggestive of ACS but without ischemic
ECG Changes or an initial positive
troponin test
CCTA
Standard Evaluation
Primary End Point, length of stay in the
hospital
P
I
C
O
Secondary Endpoints Rates of direct discharge from the ED
Cumulative costs
Cumulative radiation exposure
Time to diagnosis
Safety variables (Periprocedural
complications, undetected acute coronary
syndrome within 72 hrs after discharge,
MACE at 28 days)
Utilization of other diagnostic testing
Resource utilization
Inclusion Criteria
Patients with > 5 min of Chest Pain or Angina Equivelant within the past 24 hours
40 to 74 years of age
sinus rhythm Patients
Patient must be able to Hold Breath >10 seconds
Patient must be able to sign an informed consent
Exclusion Criteria
History of known coronary artery disease !!
New diagnostic ischemic changes on the initial ECG
Initial troponin level in excess of the 99th percentile of the local assay
Impaired renal function
Hemodynamic or clinical instability,
Known allergy to an iodinated contrast agent
Body Mass Index greater than 40
Currently symptomatic asthma.
Was the assignment of
patients to treatments
randomized? Yes, randomly assigned in a 1:1 ratio
Was the randomization
Concealed ?
No
Were the groups similar at
the start of the trial?
Yes
Aside from the allocated
treatment were groups treated
equally? Yes, and both arms were Followed up for 28
Days
Were all patients who entered
the trial accounted for?
No, Almost 1% lost the Follow up
Were Patients analysed in the
groups to which they were
randomized? Yes, with the use of intention to treat analysis
Were measures objective
? Yes, they were objectives (Length of
stay and cost and Radiation Exposure)
Were the patients and
clinicians kept “blind” to
which treatment was being
received? No, it wasn’t Blind
Results
Summary
CCTA has:
High Diagnostic Accuracy
Less Time to Dx
More Direct Discharge From ER
Reduce Length of stay
More cost !!
More Radiation
Will the results help me in
caring for my patient?
Yes, But to a limited group of patients
Applicability of the study
Patients were recruited at weekday daytime hours
Patients with History of
Known coronary artery disease
Hemodynamic or clinical instability
Impaired renal function
Limited age group
were excluded
We can Apply CCTA in our institution