title: Diagnostic performance and cost of CT angiography versus stress ECG--a randomized prospective study of suspected acute coronary syndrome chest pain in the emergency department (CT-COMPARE).
abstract: BACKGROUND
  Coronary CT angiography (CCTA) has high sensitivity, with 3 recent randomized trials favorably comparing CCTA to standard-of-care. Comparison to exercise stress ECG (ExECG), the most available and least expensive standard-of-care worldwide, has not been systematically tested.
  
  
  METHODS
  CT-COMPARE was a randomized, single-center trial of low-intermediate risk chest pain subjects undergoing CCTA or ExECG after the first negative troponin. From March 2010 to April 2011, 562 patients randomized to either dual-source CCTA (n=322) or ExECG (n=240). Primary endpoints were diagnostic performance for ACS, and hospital cost at 30 days. Secondary endpoints were time-to-discharge, admission rates, and downstream resource utilization.
  
  
  RESULTS
  ACS occurred in 24 (4%) patients. ExECG had 213 negative studies and 27 (26%) positive studies for ACS with sensitivity of 83% [95% CI: 36, 99.6%], specificity of 91% [CI: 86, 94%], and ROC AUC of 0.87 [CI: 0.70, 1]. CCTA (>50% stenosis considered positive) had 288 negative studies and 18/35 (51%) positive studies with a sensitivity of 100% [CI: 81.5, 100], specificity of 94% [CI: 91.2, 96.7%], and ROC of 0.97 [CI: 0.92, 1.0; p=0.2]. Despite CCTA having higher odds of downstream testing (OR 2.0), 30 day per-patient cost was significantly lower for CCTA ($2193 vs $2704, p<0.001). Length of stay for CCTA was significantly reduced (13.5h [95% CI: 11.2-15.7], ExECG 19.7h [95% CI: 17.4-22.1], p<0.0005), which drove the reduction in cost. No patient had post-discharge cardiovascular events at 30 days.
  
  
  CONCLUSIONS
  CCTA had improved diagnostic performance compared to ExECG, combined with 35% relative reduction in length-of-stay, and 20% reduction in hospital costs. These data lend further evidence that CCTA is useful as a first line assessment in emergency department chest pain.
authors.affiliation: Heart and Lung Institute, The Prince Charles Hospital, Brisbane, Australia; University of Queensland, Brisbane, Australia; University of Washington, Seattle, WA, United States.
authors.forename: Christian
authors.initials: C
authors.lastname: Hamilton-Craig
authors.affiliation: Heart and Lung Institute, The Prince Charles Hospital, Brisbane, Australia.
authors.forename: Allison
authors.initials: A
authors.lastname: Fifoot
authors.affiliation: Heart and Lung Institute, The Prince Charles Hospital, Brisbane, Australia.
authors.forename: Mark
authors.initials: M
authors.lastname: Hansen
authors.affiliation: Heart and Lung Institute, The Prince Charles Hospital, Brisbane, Australia.
authors.forename: Matthew
authors.initials: M
authors.lastname: Pincus
authors.affiliation: Heart and Lung Institute, The Prince Charles Hospital, Brisbane, Australia; Population and Social Health Research Program, Griffith University, Australia.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Chan
authors.affiliation: Heart and Lung Institute, The Prince Charles Hospital, Brisbane, Australia; University of Queensland, Brisbane, Australia.
authors.forename: Darren L
authors.initials: DL
authors.lastname: Walters
authors.affiliation: University of Washington, Seattle, WA, United States.
authors.forename: Kelley R
authors.initials: KR
authors.lastname: Branch
mesh_terms: D054058:Acute Coronary Syndrome / Q000000981:diagnostic imaging* / Q000191:economics; D000328:Adult; D002637:Chest Pain / Q000000981:diagnostic imaging* / Q000191:economics; D017023:Coronary Angiography / Q000191:economics / Q000592:standards*; D004636:Emergency Service, Hospital / Q000191:economics / Q000592:standards*; D005260:Female; D005500:Follow-Up Studies; D017721:Hospital Costs; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D014057:Tomography, X-Ray Computed / Q000191:economics / Q000592:standards*
keywords: Acute coronary syndrome; Coronary CT; Diagnostic performance; Exercise ECG