title: Sex differences in the effectiveness of early coronary computed tomographic angiography compared with standard emergency department evaluation for acute chest pain: the rule-out myocardial infarction with Computer-Assisted Tomography (ROMICAT)-II Trial.
abstract: BACKGROUND
  We evaluate sex-based differences in the effectiveness of early cardiac computed tomographic angiography (CCTA) and standard emergency department (ED) evaluation in patients with acute chest pain.
  
  
  RESULTS
  In the Rule-Out Myocardial Infarction With Computer-Assisted Tomography (ROMICAT)-II multicenter, controlled trial, we randomized 1000 patients (47% women) 40 to 74 years of age with symptoms suggestive of acute coronary syndrome to an early CCTA or standard ED evaluation. In this prespecified analysis, women in the CCTA arm had a greater reduction in length of stay, lower hospital admission rates, and lesser increased cumulative radiation dose than men in a comparison of ED strategies (P for interaction ≤0.02). Although women had lower acute coronary syndrome rates than men (3% versus 12%; P<0.0001), sex differences in length of stay persisted after adjustment for baseline differences, including acute coronary syndrome rate (P for interaction <0.03). Length of stay was similar between sexes with normal CCTA findings (P=0.11). There was no missed acute coronary syndrome for either sex. No difference was observed in major adverse cardiac events between sexes and ED strategies (P for interaction =0.39). Women had more normal CCTA examinations than men (58% versus 37%; P<0.0001), less obstructive coronary disease by CCTA (5% versus 17%; P=0.0001), but similar normalcy rates for functional testing (P=0.65). Men in the CCTA arm had the highest rate of invasive coronary angiography (18%), whereas women had comparable low 5% rates regardless of ED strategy.
  
  
  CONCLUSIONS
  This trial provides data supporting an early CCTA strategy as an attractive option in women presenting to the ED with symptoms suggestive of acute coronary syndrome. The findings may be explained by lower CAD prevalence and severity in women than men.
  
  
  BACKGROUND
  http://www.clinicaltrials.gov. Unique identifier: NCT01084239.
authors.affiliation: Cardiac MR PET CT Program, Division of Cardiology and Department of Radiology, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge St, Ste 400, Boston, MA 02114, USA. qtruong@partners.org
authors.forename: Quynh A
authors.initials: QA
authors.lastname: Truong
authors.forename: Douglas
authors.initials: D
authors.lastname: Hayden
authors.forename: Pamela K
authors.initials: PK
authors.lastname: Woodard
authors.forename: Ruth
authors.initials: R
authors.lastname: Kirby
authors.forename: Eric T
authors.initials: ET
authors.lastname: Chou
authors.forename: John T
authors.initials: JT
authors.lastname: Nagurney
authors.forename: Stephen D
authors.initials: SD
authors.lastname: Wiviott
authors.forename: Jerome L
authors.initials: JL
authors.lastname: Fleg
authors.forename: David A
authors.initials: DA
authors.lastname: Schoenfeld
authors.forename: James E
authors.initials: JE
authors.lastname: Udelson
authors.forename: Udo
authors.initials: U
authors.lastname: Hoffmann
mesh_terms: D054058:Acute Coronary Syndrome / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000453:epidemiology; D000208:Acute Disease; D000328:Adult; D000368:Aged; D002637:Chest Pain / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000453:epidemiology; D017023:Coronary Angiography; D003937:Diagnosis, Differential; D003955:Diagnostic Tests, Routine; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000453:epidemiology; D015995:Prevalence; D012720:Severity of Illness Index; D014057:Tomography, X-Ray Computed
keywords: acute coronary syndrome; chest pain; emergency service, hospital; sex; tomography, x-ray computed