title: Coronary CT angiography for acute chest pain in the emergency department.
abstract: Acute chest pain in the emergency department (ED) is a common and costly public health challenge. The traditional strategy of evaluating acute chest pain by hospital or ED observation over a period of several hours, serial electrocardiography and cardiac biomarkers, and subsequent diagnostic testing such as physiologic stress testing is safe and effective. Yet this approach has been criticized for being time intensive and costly. This review evaluates the current medical evidence which has demonstrated the potential for coronary CT angiography (CTA) assessment of acute chest pain to safely reduce ED cost, time to discharge, and rate of hospital admission. These benefits must be weighed against the risk of ionizing radiation exposure and the influence of ED testing on rates of downstream coronary angiography and revascularization. Efforts at radiation minimization have quickly evolved, implementing technology such as prospective electrocardiographic gating and high pitch acquisition to significantly reduce radiation exposure over just a few years. CTA in the ED has demonstrated accuracy, safety, and the ability to reduce ED cost and crowding although its big-picture effect on total hospital and health care system cost extends far beyond the ED. The net effect of CTA is dependent also on the prevalence of coronary artery disease (CAD) in the population where CTA is used, which significantly influences rates of post-CTA invasive procedures such as angiography and coronary revascularization. These potential costs and benefits will warrant careful consideration and prospective monitoring as additional hospitals continue to implement this important technology into their diagnostic regimen.
authors.affiliation: Division of Internal Medicine, Center for Clinical and Epidemiological Research, University of Sao Paulo, Sao Paulo, Brazil.
authors.forename: Henrique Lane
authors.initials: HL
authors.lastname: Staniak
authors.affiliation: Division of Internal Medicine, Center for Clinical and Epidemiological Research, University of Sao Paulo, Sao Paulo, Brazil.
authors.forename: Marcio Sommer
authors.initials: MS
authors.lastname: Bittencourt
authors.affiliation: Cardiology Service, Department of Medicine, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889, USA; Uniformed Services University of Health Sciences, 8901 Wisconsin Avenue, Bethesda, MD 20889, USA.
authors.forename: Christopher
authors.initials: C
authors.lastname: Pickett
authors.affiliation: Cardiology Service, Department of Medicine, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889, USA; Uniformed Services University of Health Sciences, 8901 Wisconsin Avenue, Bethesda, MD 20889, USA.
authors.forename: Michael
authors.initials: M
authors.lastname: Cahill
authors.affiliation: Cardiology Service, Department of Medicine, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889, USA; Uniformed Services University of Health Sciences, 8901 Wisconsin Avenue, Bethesda, MD 20889, USA.
authors.forename: David
authors.initials: D
authors.lastname: Kassop
authors.affiliation: Cardiology Service MCHE-MDC, San Antonio Military Medical Center, Brooke Army Medical Center, San Antonio, TX, USA.
authors.forename: Ahmad
authors.initials: A
authors.lastname: Slim
authors.affiliation: Noninvasive Cardiovascular Imaging Program, Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA; Department of Radiology, Harvard Medical School, Boston, MA, USA.
authors.forename: Ron
authors.initials: R
authors.lastname: Blankstein
authors.affiliation: Cardiology Service, Department of Medicine, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889, USA; Uniformed Services University of Health Sciences, 8901 Wisconsin Avenue, Bethesda, MD 20889, USA. Electronic address: edward.hulten@us.army.mil.
authors.forename: Edward
authors.initials: E
authors.lastname: Hulten
mesh_terms: D000208:Acute Disease; D002637:Chest Pain / Q000000981:diagnostic imaging*; D017023:Coronary Angiography / Q000379:methods*; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging*; D004636:Emergency Service, Hospital / Q000458:organization & administration*; D006801:Humans; D007902:Length of Stay; D013902:Radiography, Thoracic / Q000379:methods*; D014057:Tomography, X-Ray Computed / Q000379:methods*
keywords: Cardiac; Chest pain; Coronary computed tomography angiography; Emergency department