title: Meta-analysis of coronary computed tomography angiography versus standard of care strategy for the evaluation of low risk chest pain: are randomized controlled trials and cohort studies showing the same evidence?
abstract: BACKGROUND
  Randomized control trials (RCTs) have established the use of Coronary Computed Tomography Angiography (CCTA) for the evaluation of low to intermediate risk patients presenting with acute chest pain to the emergency department (ED). However, concerns remain regarding the downstream resource utilization and the clinical impact of such strategy.
  
  
  METHODS
  We performed a meta-analysis of existing studies to compare CCTA to the standard of care (SOC) strategies in the low to intermediate risk chest pain patients. We abstracted the reported incidence of acute coronary syndromes (ACS), the total number of invasive coronary angiography (ICA) and subsequent revascularization procedures, the rates of hospital readmissions and repeat ED visits. We stratified the results according to the type of the studies (randomized or not) and used random effect analysis for the studied outcomes.
  
  
  RESULTS
  Four RCTs and 3 case-control studies with 3306 patients undergoing CCTA and 2752 assigned to SOC were included in the analysis. Following the index visit, we observed a significant reduction in the risk of ACS (RR: 0.26, 95% CI, 0.08 to 0.87; p = 0.03) and in the rates of repeat ED visits (RR: 0.58, 95% CI: 0.36 to 0.94; p = 0.03). In addition, a trend toward less hospital readmission (p = 0.07) was noted. There was no difference in ICA (p = 0.99) but an increase in revascularization procedures (RR: 1.46, 95% CI: 1.09 to 1.94; p = 0.01).
  
  
  CONCLUSIONS
  CCTA use in the ED for the triage of low to intermediate risk patients reduces the risk of future ACS and subsequent ED visits for chest pain.
authors.affiliation: Mount Sinai Saint Luke's Hospital, New York, NY, United States.
authors.forename: Georges
authors.initials: G
authors.lastname: El-Hayek
authors.affiliation: Ochsner Medical Center, New Orleans, LA, United States.
authors.forename: Alexandre
authors.initials: A
authors.lastname: Benjo
authors.affiliation: Morristown Medical Center, Morristown, NJ, United States.
authors.forename: Seth
authors.initials: S
authors.lastname: Uretsky
authors.affiliation: Wayne State University, Detroit, MI, United States; King Abdul Aziz Cardiac Center, Riyadh, Saudi Arabia.
authors.forename: Mouaz
authors.initials: M
authors.lastname: Al-Mallah
authors.affiliation: Mount Sinai Saint Luke's Hospital, New York, NY, United States.
authors.forename: Randy
authors.initials: R
authors.lastname: Cohen
authors.affiliation: Mount Sinai Saint Luke's Hospital, New York, NY, United States.
authors.forename: Daniel
authors.initials: D
authors.lastname: Bamira
authors.affiliation: Mount Sinai Saint Luke's Hospital, New York, NY, United States.
authors.forename: Patricia
authors.initials: P
authors.lastname: Chavez
authors.affiliation: Mount Sinai Medical Center, Miami Beach, FL, United States.
authors.forename: Francisco
authors.initials: F
authors.lastname: Nascimento
authors.affiliation: Mount Sinai Medical Center, Miami Beach, FL, United States.
authors.forename: Orlando
authors.initials: O
authors.lastname: Santana
authors.affiliation: Ochsner Medical Center, New Orleans, LA, United States.
authors.forename: Rajan
authors.initials: R
authors.lastname: Patel
authors.affiliation: Heart & Vascular Institute, UPMC-University of Pittsburgh, Pittsburgh, PA, United States. Electronic address: cavalcantejl@upmc.edu.
authors.forename: João L
authors.initials: JL
authors.lastname: Cavalcante
mesh_terms: D002637:Chest Pain / Q000000981:diagnostic imaging* / Q000209:etiology; D015331:Cohort Studies; D017023:Coronary Angiography / Q000379:methods*; D003324:Coronary Artery Disease / Q000150:complications* / Q000000981:diagnostic imaging; D006801:Humans; D016032:Randomized Controlled Trials as Topic; D059039:Standard of Care / Q000458:organization & administration*; D014057:Tomography, X-Ray Computed / Q000379:methods*; D014218:Triage / Q000379:methods*
keywords: Acute chest pain; Coronary computed tomography angiography; Meta-analysis; Standard of care