CORRESPONDENCE: LETTER TO THE EDITOR
Immediate Coronary Imaging for Acute Chest Pain: Are We There Yet?
Fernando Alfonso, MD, PhD, FESC*
* H Clinico San Carlos, Interventional Cardiology, Plaza Cristo Rey, Madrid 28040, Spain (Email: falf{at}hotmail.com).
We read with great interest the elegant study by Goldstein et al. (1) suggesting the value of multislice coronary computed tomography (MSCT) in the evaluation of acute chest pain patients. The investigators should be commended for this landmark trial that constitutes one of the few studies assessing the value of an imaging diagnostic technique using a randomized design. As compared with patients managed in the emergency department with standard of care measures, those assigned to the MSCT arm not only had reduced diagnostic times and costs but also required less frequently repeated evaluations for recurrent chest pain (1). Considering the potential clinical implications of this provocative study, addressing some methodological issues would be appreciated.
First, in a randomized study defining the sample size calculation is critical. This is especially relevant considering the very-low-risk patient population included in the present study (none of the patients suffered an event after discharge). Likewise, the primary outcome measure of the study was not clearly stated. Therefore, the value and implications of the different study findings remain difficult to establish. Second, the main study findings basically relate to the reduced diagnostic time found in the MSCT arm (3.4 vs. 15 h). However, precise data concerning the time required to access/perform/interpret MSCT versus the nuclear test studies were not provided. This information is of particular interest because improved logistics in the nuclear stress arm could have modified the results. It remains possible that a "fast tracked" access to the MSCT (driven by the investigators’ scientific interest) was not correlated with a similar enthusiasm in the nuclear arm. This is important considering that 95% of patients allocated to the nuclear arm were sent home after a negative scan, whereas 24% of patients randomized to MSCT eventually required a nuclear study before discharge as the result of either nondiagnostic results or intermediate lesions on MSCT. In fact, fewer patients in the MSCT arm could be discharged directly from the emergency department. Finally, it is likely that the use of alternative standard of care measures would have affected the results. In Europe, many patients evaluated in chest pain units are scheduled for an early conventional exercise test (2–4). This technique seems especially attractive for very-low-risk patients (such as those in the current study), avoids radiation exposure, is widely available and easily performed from a logistic perspective, and above all, is much cheaper.
We fully agree with the suggestion of Goldstein et al. (1) regarding the need of further studies to clarify how the impressive diagnostic capability of MSCT can be best implemented in clinical practice.
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References
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- Goldstein JA, Gallagher MJ, O’Neill WW, et al. A randomized controlled trial of multi-slice coronary computed tomography for evaluation of acute chest pain J Am Coll Cardiol 2007;49;:863-871.[Abstract/Free Full Text]
- Sanchis J, Bodi V, Llacer A, Nuñez J, Ferrero JA, Chorro FJ. Value of early exercise stress testing in a chest pain unit protocol Rev Esp Cardiol 2002;55:1089-1092.[ISI][Medline]
- Martinez-Selles M, Ortiz J, Estevez A, Andueza J, de Miguel J, Bueno H. A new risk score for patients with a normal or non-diagnostic ECG admitted to a chest pain unit Rev Esp Cardiol 2005;58:782-788.[CrossRef][ISI][Medline]
- Castillo Moreno JA, Ramos Martin JL, Molina Laborda E, et al. Usefulness of clinical profiling and exercise testing in the prognostic assessment of patients admitted with chest pain but without high-risk criteria Rev Esp Cardiol 2006;59:12-19.[CrossRef][ISI][Medline]
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- James A. Goldstein and Gilbert L. Raff
J. Am. Coll. Cardiol. 2007 50: 651.
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