title: Rationale and design of a randomized trial comparing initial stress echocardiography versus coronary CT angiography in low-to-intermediate risk emergency department patients with chest pain.
abstract: BACKGROUND
  Comparative effectiveness research (CER) has become a major focus of cardiovascular disease investigation to optimize diagnosis and treatment paradigms and decrease healthcare expenditures. Acute chest pain is a highly prevalent reason for evaluation in the Emergency Department (ED) that results in hospital admission for many patients and excess expense. Improvement in noninvasive diagnostic algorithms can potentially reduce unnecessary admissions.
  
  
  OBJECTIVE
  To compare the performance of treadmill stress echocardiography (SE) and coronary computed tomography angiography (CTA) in ED chest pain patients with low-to-intermediate risk of significant coronary artery disease.
  
  
  METHODS
  This is a single-center, randomized controlled trial (RCT) comparing SE and CTA head-to-head as the initial noninvasive imaging modality. The primary outcome measured is the incidence of hospitalization. The study is powered to detect a reduction in admissions from 28% to 15% with a sample size of 400. Secondary outcomes include length of stay in the ED/hospital and estimated cost of care. Safety outcomes include subsequent visits to the ED and hospitalizations, as well as major adverse cardiovascular events at 30 days and 1 year. Patients who do not meet study criteria or do not consent for randomization are offered entry into an observational registry.
  
  
  CONCLUSIONS
  This RCT will add to our understanding of the roles of different imaging modalities in triaging patients with suspected angina. It will increase the CER evidence base comparing SE and CTA and provide insight into potential benefits and limitations of appropriate use of treadmill SE in the ED.
authors.affiliation: Department of Radiology, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, New York.
authors.forename: Jeffrey M
authors.initials: JM
authors.lastname: Levsky
authors.forename: Linda B
authors.initials: LB
authors.lastname: Haramati
authors.forename: Cynthia C
authors.initials: CC
authors.lastname: Taub
authors.forename: Daniel M
authors.initials: DM
authors.lastname: Spevack
authors.forename: Mark A
authors.initials: MA
authors.lastname: Menegus
authors.forename: Mark I
authors.initials: MI
authors.lastname: Travin
authors.forename: Shayna
authors.initials: S
authors.lastname: Vega
authors.forename: Rikah
authors.initials: R
authors.lastname: Lerer
authors.forename: Durline
authors.initials: D
authors.lastname: Brown-Manhertz
authors.forename: Esther
authors.initials: E
authors.lastname: Hirschhorn
authors.forename: Jonathan N
authors.initials: JN
authors.lastname: Tobin
authors.forename: Mario J
authors.initials: MJ
authors.lastname: Garcia
mesh_terms: D000328:Adult; D000369:Aged, 80 and over; D015984:Causality; D002637:Chest Pain / Q000175:diagnosis / Q000191:economics* / Q000453:epidemiology; D015897:Comorbidity; D017023:Coronary Angiography / Q000191:economics / Q000706:statistics & numerical data; D003324:Coronary Artery Disease / Q000175:diagnosis* / Q000191:economics* / Q000453:epidemiology; D004452:Echocardiography / Q000191:economics* / Q000706:statistics & numerical data; D004636:Emergency Service, Hospital / Q000191:economics*; D005080:Exercise Test / Q000191:economics* / Q000706:statistics & numerical data; D005260:Female; D017048:Health Care Costs / Q000706:statistics & numerical data; D006760:Hospitalization / Q000191:economics; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D009518:New York / Q000453:epidemiology; D012107:Research Design; D018570:Risk Assessment; D014057:Tomography, X-Ray Computed / Q000191:economics* / Q000706:statistics & numerical data; D055815:Young Adult
keywords: chest pain; comparative effectiveness research; coronary computed tomography angiography; emergency department; randomized controlled trial; stress echocardiography