Coronary Computed Tomography Angiography Versus Traditional Care: Comparison of One-Year Outcomes and Resource Use.
OBJECTIVE
Three large, multicenter, randomized, clinical trials have shown that coronary computed tomography (CT) angiography allows efficient evaluation and safe discharge of patients with low- to intermediate-risk chest pain who present to the emergency department (ED). We report 1-year event rates and resource use from the American College of Radiology Imaging Network-Pennsylvania 4005 multicenter trial.


METHODS
Patients with low- to intermediate-risk chest pain and presenting to the ED were randomized in a 2:1 ratio to a coronary CT angiography care pathway or traditional care. Subjects were contacted by telephone at least 1 year after ED presentation. Medical record review was performed for all cardiac hospitalizations, procedures and diagnostic tests, and adverse cardiac events. Our main outcome was the composite of cardiac death and myocardial infarction within 1 year. The secondary outcome was resource use.


RESULTS
One thousand three hundred sixty-eight patients enrolled and 1,285 (94%) had direct participant or proxy contact at 1 year. All others had record review or death index search. From index presentation through 1 year, there was no difference between patients in the coronary CT angiography arm versus traditional care with respect to major adverse cardiac event (1.4% versus 1.1%; difference 0.3%; 95% CI -5.5% to 6.0%). From hospital discharge through 1 year, there was also no difference in ED revisits (36% versus 38%; difference -2.1%; 95% CI -7.9% to 3.7%), hospital admissions (16% versus 17%; difference -0.9%; 95% CI -6.7% to 4.9%), or subsequent cardiac testing (13% versus 13%; difference -0.4%; 95% CI -6.2% to 5.5%). One of 640 subjects with a negative coronary CT angiography result had a major adverse cardiac event within 1 year of presentation (0.16%; 95% CI 0.004% to 0.87%).


CONCLUSIONS
A coronary CT angiography-based strategy for evaluation of patients with low- to intermediate-risk chest pain who present to the ED does not result in increased resource use during 1 year. A negative coronary CT angiography result is associated with a less than 1% major adverse cardiac event rate during the first year after testing.
Department of Emergency Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA. Electronic address: judd.hollander@jefferson.edu.
Judd E
JE
Hollander
Center for Statistical Sciences, Brown University School of Public Health, Providence, RI; Department of Biostatistics, Brown University School of Public Health, Providence, RI.
Constantine
C
Gatsonis
Center for Statistical Sciences, Brown University School of Public Health, Providence, RI.
Erin M
EM
Greco
Center for Statistical Sciences, Brown University School of Public Health, Providence, RI.
Bradley S
BS
Snyder
Department of Emergency Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA.
Anna Marie
AM
Chang
Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC.
Chadwick D
CD
Miller
Department of Radiology, Penn State Hershey Medical Center, Hershey, PA.
Harjit
H
Singh
Department of Radiology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA.
Harold I
HI
Litt
D000328:Adult; D000368:Aged; D002637:Chest Pain / Q000000981:diagnostic imaging* / Q000401:mortality; D017023:Coronary Angiography / Q000379:methods*; D004562:Electrocardiography; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000000981:diagnostic imaging* / Q000401:mortality; D010414:Pennsylvania; D011237:Predictive Value of Tests; D011446:Prospective Studies; D011795:Surveys and Questionnaires; D014057:Tomography, X-Ray Computed