Safety of a Coronary Computed Tomography Angiography-guided Strategy for Assessment of Chest Pain in the Emergency Department

Abstract

Background: Coronary computed tomography angiography (CCTA) is increasingly being used in Emergency Departments (ED) for the diagnostic work-up of patients with low-to-intermediate risk chest pain, however limited data exists on the safety of such an approach. Methods: We prospectively evaluated 335 consecutive patients who presented to ED between September 2008 and March 2010 with low-to-intermediate risk (TIMI 0-4) ischaemic-type chest pain and were evaluated with 320-detector CCTA (dose-modulated retrospective electrocardiogram-triggering) after normal single or serial troponin measurement and normal electrocardiogram. Patients with previous significant coronary stenoses or previous revascularisation were excluded. Patients without any plaque or mild stenoses onCCTAwere discharged with no further investigation. Patients with moderate stenoses were discharged with outpatient stress echocardiography. Patients with severe stenoses were admitted for invasive angiography. Discharged patients were contacted by telephone and medical recordswere reviewed to determine safety outcomes. Results: Mean age was 57(plus or minus)11 years (59% male). 274 patients (82%) had no plaque or mild stenoses on CCTA andwere discharged with no further investigation, 13 (4%) had moderate stenoses on CCTA and were discharged with outpatient stress echocardiography and 48 (14%) had severe stenoses on CCTA and were admitted for invasive angiography. At mean 18.8-month follow-up (range 12-29 months), there was one (0.003%) chest pain readmission, and there were no myocardial infarctions or deaths. Conclusions: Triaging low-to-intermediate risk patients with a CCTA-guided strategy allows early discharge of the majority of patients with a very lowrate of clinical sequelae at mean 18.8-month follow-up.