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J Am Coll Cardiol, 2007; 49:863-871, doi:10.1016/j.jacc.2006.08.064 (Published online 9 February 2007).
© 2007 by the American College of Cardiology Foundation
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CLINICAL RESEARCH: CARDIAC IMAGING

A Randomized Controlled Trial of Multi-Slice Coronary Computed Tomography for Evaluation of Acute Chest Pain

James A. Goldstein, MD, FACC, Michael J. Gallagher, MD, William W. O'Neill, MD, FACC, Michael A. Ross, MD, FACEP, Brian J. O'Neil, MD, FACEP and Gilbert L. Raff, MD, FACC*

William Beaumont Hospital, Royal Oak, Michigan

Manuscript received June 2, 2006; revised manuscript received August 11, 2006, accepted August 28, 2006.

* Reprint requests and correspondence: Dr. Gilbert L. Raff, William Beaumont Hospital, 3601 West 13 Mile Road, Royal Oak, Michigan 48073. (Email: graff{at}beaumont.edu).

OBJECTIVES: This study sought to compare the safety, diagnostic efficacy, and efficiency of multi-slice computed tomography (MSCT) with standard diagnostic evaluation of low-risk acute chest pain patients.

BACKGROUND: Over 1 million patients have emergency center evaluations for acute chest pain annually, at an estimated diagnostic cost of over $10 billion. Multi-slice computed tomography has a high negative predictive value for exclusion of coronary artery stenoses.

METHODS: We randomized patients to MSCT (n = 99) versus SOC (n = 98) protocols. The MSCT patients with minimal disease were discharged; those with stenosis >70% underwent catheterization, whereas cases with intermediate lesions or non-diagnostic scans underwent stress testing. Outcomes included: safety (freedom from major adverse events over 6 months), diagnostic efficacy (clinically correct and definitive diagnosis), as well as time and cost of care.

RESULTS: Both approaches were completely (100%) safe. The MSCT alone immediately excluded or identified coronary disease as the source of chest pain in 75% of patients, including 67 with normal coronary arteries and 8 with severe disease referred for invasive evaluation. The remaining 25% of patients required stress testing, owing to intermediate severity lesions or non-diagnostic scans. During the index visit, MSCT evaluation reduced diagnostic time compared with SOC (3.4 h vs. 15.0 h, p < 0.001) and lowered costs ($1,586 vs. $1,872, p < 0.001). Importantly, MSCT patients required fewer repeat evaluations for recurrent chest pain (MSCT, 2 of 99 (2.0%) patients vs. SOC, 7 of 99 (7%) patients; p = 0.10).

CONCLUSIONS: Multi-slice computed tomographic coronary angiography can definitively establish or exclude coronary disease as the cause of chest pain. However, inability to determine the physiological significance of intermediate severity coronary lesions and cases with inadequate image quality are present limitations. (Study of Coronary Artery Computed Tomography to Diagnose Emergency Chest Pain CR; http://clinicaltrials.gov/ct/show/NCT00273832?order=1; NCT00273832 [ClinicalTrials.gov] )

Abbreviations and Acronyms
  ECG = electrocardiogram
  ED = emergency department
  MACE = major adverse cardiac event
  MSCT = multi-slice computed tomography
  SOC = standard of care


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 RadiologyHome page
C. S. White and D. Kuo
Chest Pain in the Emergency Department: Role of Multidetector CT
Radiology, December 1, 2007; 245(3): 672 - 681.
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 HeartHome page
S. K Seneviratne, F. Bamberg, and U. Hoffmann
CT angiography: front line for acute coronary syndromes now?
Heart, November 1, 2007; 93(11): 1325 - 1326.
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 CirculationHome page
R. Rubinshtein, D. A. Halon, R. Jaffe, B. Karkabi, M. Y. Flugelman, B. S. Lewis, T. Gaspar, N. Peled, A. Kogan, and R. Shapira
Response to Letter Regarding Article, "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, September 18, 2007; 116(12): e355 - e355.
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 J Am Coll CardiolHome page
R. J. Gibbons, P. A. Araoz, and E. E. Williamson
The Year in Cardiac Imaging
J. Am. Coll. Cardiol., September 4, 2007; 50(10): 988 - 1003.
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 J Am Coll CardiolHome page
F. Alfonso
Immediate Coronary Imaging for Acute Chest Pain: Are We There Yet?
J. Am. Coll. Cardiol., August 14, 2007; 50(7): 650 - 651.
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 J Am Coll CardiolHome page
G. L. Raff and J. A. Goldstein
Coronary Angiography by Computed Tomography: Coronary Imaging Evolves
J. Am. Coll. Cardiol., May 8, 2007; 49(18): 1830 - 1833.
[Abstract] [Full Text] [PDF]

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 JWatch Emergency Med.Home page
Multislice Coronary CT in Low-Risk Patients with Chest Pain
Journal Watch Emergency Medicine, May 4, 2007; 2007(504): 4 - 4.
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 JWatch GeneralHome page
Multislice CT for Evaluation of Acute Chest Pain in the ED?
Journal Watch (General), April 3, 2007; 2007(403): 5 - 5.
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 J Am Coll CardiolHome page
P. J. de Feyter and N. van Pelt
Spiral Computed Tomography Coronary Angiography: A New Diagnostic Tool Developing Its Role in Clinical Cardiology
J. Am. Coll. Cardiol., February 27, 2007; 49(8): 872 - 874.
[Full Text] [PDF]


 
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