title: Triage of patients presenting with chest pain to the emergency department: implementation of coronary CT angiography in a large urban health care system.
abstract: OBJECTIVE
  There is growing evidence supporting the use of coronary CT angiography (CTA) to triage patients in the emergency department (ED) with acute chest pain and low risk of acute coronary syndrome (ACS). We hypothesized that coronary CTA can guide early management and safely discharge patients by introducing a dedicated patient management protocol.
  
  
  METHODS
  We conducted a prospective cohort study in three EDs of a large health care system (> 1300 beds). Five hundred twenty-nine patients (mean age, 52.1 years; 56% women) with chest pain, negative cardiac enzyme results, normal or nondiagnostic ECG findings, and a thrombolysis in myocardial infarction (TIMI) risk score of 2 or less were admitted and underwent CTA. A new dedicated chest pain triage protocol (levels 1-5) was implemented. On the basis of CTA findings, patients were stratified into one of the following four groups: 0, low (negative CTA findings); 1, mild (1-49% stenosis); 2, moderate (50-69% stenosis); or 3, severe (≥ 70% stenosis) risk of ACS. Outcome measures included major adverse cardiac events (MACEs) during the first 30 days after CTA, downstream testing results, and length of stay (LOS). LOS was compared before and after implementation of our chest pain triage protocol.
  
  
  RESULTS
  Three hundred seventeen patients (59.9%) with negative CTA findings and 151 (28.5%) with mild stenosis were discharged from the ED with a very low downstream testing rate and a very low MACE rate (negative predictive value = 99.8%). Twenty-five patients (4.7%) had moderate stenosis (n = 17 undergoing further testing). Thirty-six patients (6.8%) had stenosis of 70% or greater by CTA (n = 34 positive by invasive angiography or SPECT-myocardial perfusion imaging). The sensitivity of CTA was 94%. The rate of MACEs in patients with stenosis of 70% or greater (8.3%) was significantly higher (p < 0.001) than in patients with negative CTA findings (0%) or those with mild stenosis (0.2%). A 51% decrease in LOS-from 28.8 to 14.0 hours--was noted after implementation of the dedicated chest pain protocol (p < 0.001).
  
  
  CONCLUSIONS
  Chest pain patients with negative or mild nonobstructive CTA findings can be safely discharged from the ED without further testing. Implementation of a dedicated chest pain triage protocol is critical for the success of a coronary CTA program.
authors.affiliation: Baptist Health of South Florida and Baptist Cardiac and Vascular Institute, 8900 N Kendall Dr, Miami, FL 33176, USA. rcury@baptisthealth.net
authors.forename: Ricardo C
authors.initials: RC
authors.lastname: Cury
authors.forename: Gudrun M
authors.initials: GM
authors.lastname: Feuchtner
authors.forename: Juan C
authors.initials: JC
authors.lastname: Batlle
authors.forename: Constantino S
authors.initials: CS
authors.lastname: Peña
authors.forename: Warren
authors.initials: W
authors.lastname: Janowitz
authors.forename: Barry T
authors.initials: BT
authors.lastname: Katzen
authors.forename: Jack A
authors.initials: JA
authors.lastname: Ziffer
mesh_terms: D054058:Acute Coronary Syndrome / Q000000981:diagnostic imaging* / Q000628:therapy; D002637:Chest Pain / Q000000981:diagnostic imaging* / Q000628:therapy; D017023:Coronary Angiography; D023921:Coronary Stenosis / Q000000981:diagnostic imaging / Q000628:therapy; D004636:Emergency Service, Hospital; D005260:Female; D006760:Hospitalization; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D011829:Radiation Dosage; D018570:Risk Assessment; D014057:Tomography, X-Ray Computed; D014218:Triage