title: Coronary CT angiography versus standard evaluation in acute chest pain.
abstract: BACKGROUND
  It is unclear whether an evaluation incorporating coronary computed tomographic angiography (CCTA) is more effective than standard evaluation in the emergency department in patients with symptoms suggestive of acute coronary syndromes.
  
  
  METHODS
  In this multicenter trial, we randomly assigned patients 40 to 74 years of age with symptoms suggestive of acute coronary syndromes but without ischemic electrocardiographic changes or an initial positive troponin test to early CCTA or to standard evaluation in the emergency department on weekdays during daylight hours between April 2010 and January 2012. The primary end point was length of stay in the hospital. Secondary end points included rates of discharge from the emergency department, major adverse cardiovascular events at 28 days, and cumulative costs. Safety end points were undetected acute coronary syndromes.
  
  
  RESULTS
  The rate of acute coronary syndromes among 1000 patients with a mean (±SD) age of 54±8 years (47% women) was 8%. After early CCTA, as compared with standard evaluation, the mean length of stay in the hospital was reduced by 7.6 hours (P<0.001) and more patients were discharged directly from the emergency department (47% vs. 12%, P<0.001). There were no undetected acute coronary syndromes and no significant differences in major adverse cardiovascular events at 28 days. After CCTA, there was more downstream testing and higher radiation exposure. The cumulative mean cost of care was similar in the CCTA group and the standard-evaluation group ($4,289 and $4,060, respectively; P=0.65).
  
  
  CONCLUSIONS
  In patients in the emergency department with symptoms suggestive of acute coronary syndromes, incorporating CCTA into a triage strategy improved the efficiency of clinical decision making, as compared with a standard evaluation in the emergency department, but it resulted in an increase in downstream testing and radiation exposure with no decrease in the overall costs of care. (Funded by the National Heart, Lung, and Blood Institute; ROMICAT-II ClinicalTrials.gov number, NCT01084239.).
authors: Department of Radiology, Massachusetts General Hospital, Boston, MA 02114, USA. uhoffmann@partners.org
authors: Udo
authors: U
authors: Hoffmann
authors: Quynh A
authors: QA
authors: Truong
authors: David A
authors: DA
authors: Schoenfeld
authors: Eric T
authors: ET
authors: Chou
authors: Pamela K
authors: PK
authors: Woodard
authors: John T
authors: JT
authors: Nagurney
authors: J Hector
authors: JH
authors: Pope
authors: Thomas H
authors: TH
authors: Hauser
authors: Charles S
authors: CS
authors: White
authors: Scott G
authors: SG
authors: Weiner
authors: Shant
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authors: Kalanjian
authors: Michael E
authors: ME
authors: Mullins
authors: Issam
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authors: Mikati
authors: W Frank
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authors: Peacock
authors: Pearl
authors: P
authors: Zakroysky
authors: Douglas
authors: D
authors: Hayden
authors: Alexander
authors: A
authors: Goehler
authors: Hang
authors: H
authors: Lee
authors: G Scott
authors: GS
authors: Gazelle
authors: Stephen D
authors: SD
authors: Wiviott
authors: Jerome L
authors: JL
authors: Fleg
authors: James E
authors: JE
authors: Udelson
mesh_terms: D054058:Acute Coronary Syndrome / Q000150:complications / Q000175:diagnosis* / Q000000981:diagnostic imaging; D000328:Adult; D000368:Aged; D002637:Chest Pain / Q000000981:diagnostic imaging* / Q000209:etiology; D017023:Coronary Angiography; D004569:Electroencephalography; D004636:Emergency Service, Hospital; D005260:Female; D017048:Health Care Costs; D006295:Health Resources / Q000706:statistics & numerical data; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D014057:Tomography, X-Ray Computed