title: Optimizing Evaluation of Patients with Low-to-Intermediate-Risk Acute Chest Pain: A Randomized Study Comparing Stress Myocardial Perfusion Tomography Incorporating Stress-Only Imaging Versus Cardiac CT.
abstract: The purpose of this study was to determine whether stress myocardial perfusion (SPECT) optimized with stress-only (SO) imaging is comparable to cardiac CT angiography (CTA) for evaluating patients with acute chest pain (ACP).
  
  
  METHODS
  This was a prospective randomized observational study in 598 ACP patients who underwent CTA versus SPECT. The primary endpoint was length of hospital stay, and secondary endpoints were test feasibility, time to diagnosis, diagnostic accuracy, radiation exposure, and overall cost. Median follow-up was 6.5 mo, with a 3.8% cardiac event rate defined as death or an acute coronary syndrome.
  
  
  RESULTS
  Of 2,994 patients screened, 1,703 (56.9%) were not candidates for CTA because of prior cardiac disease (41%) or imaging contraindications (16%). Time to diagnosis (8.1 ± 8.5 vs. 9.4 ± 7.4 h) and length of hospital stay (19.7 ± 27.8 vs. 23.5 ± 34.4 h) were significantly shorter with CTA than with SPECT (P = 0.002). However, time to diagnosis (7.0 ± 6.2 vs. 6.8 ± 5.9 h, P = 0.20), length of stay (15.5 ± 17.2 vs. 16.7 ± 15.3 h, P = 0.36), and hospital costs ($4,242 ± $3,871 vs. $4,364 ± 1781, P = 0.86) were comparable with CTA versus SO SPECT, respectively. SO was also superior to conventional SPECT regarding all of the above metrics and significantly reduced radiation exposure (5.5 ± 4.4 vs. 12.5 ± 2.7 mSv, P < 0.0001).
  
  
  CONCLUSIONS
  Stress SPECT when optimized with SO imaging is similar to CTA in time to diagnosis, length of hospital stay, and cost, with improved prognostic accuracy and less radiation exposure. Our results emphasize the importance of SO imaging, particularly in low-intermediate-risk emergency room patients who are a population likely to have a normal test result.
authors.affiliation: Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas.
authors.forename: Faisal
authors.initials: F
authors.lastname: Nabi
authors.affiliation: Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas.
authors.forename: Mahwash
authors.initials: M
authors.lastname: Kassi
authors.affiliation: Division of Cardiology, Department of Medicine, University of California San Francisco, Fresno, California.
authors.forename: Kamil
authors.initials: K
authors.lastname: Muhyieddeen
authors.affiliation: Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas.
authors.forename: Su Min
authors.initials: SM
authors.lastname: Chang
authors.affiliation: Center for Biostatistics, Houston Methodist Research Institute, Houston, Texas; and.
authors.forename: Jiaqiong
authors.initials: J
authors.lastname: Xu
authors.affiliation: Center for Biostatistics, Houston Methodist Research Institute, Houston, Texas; and.
authors.forename: Leif E
authors.initials: LE
authors.lastname: Peterson
authors.affiliation: Department of Surgery, Center for Outcomes Research, Houston Methodist Research Institute, Houston, Texas.
authors.forename: Nelda P
authors.initials: NP
authors.lastname: Wray
authors.affiliation: Department of Surgery, Center for Outcomes Research, Houston Methodist Research Institute, Houston, Texas.
authors.forename: Beverly A
authors.initials: BA
authors.lastname: Shirkey
authors.affiliation: Department of Surgery, Center for Outcomes Research, Houston Methodist Research Institute, Houston, Texas.
authors.forename: Carol M
authors.initials: CM
authors.lastname: Ashton
authors.affiliation: Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, Texas jmahmarian@HoustonMethodist.org.
authors.forename: John J
authors.initials: JJ
authors.lastname: Mahmarian
mesh_terms: D000368:Aged; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D054058:Acute Coronary Syndrome / Q000453:epidemiology / Q000401:mortality; D002637:Chest Pain / Q000000981:diagnostic imaging / Q000191:economics; D016757:Death, Sudden, Cardiac / Q000453:epidemiology / Q000209:etiology; D005080:Exercise Test; D005500:Follow-Up Studies; D006321:Heart / Q000000981:diagnostic imaging; D008136:Longevity; D018810:Magnetic Resonance Angiography / Q000191:economics / Q000379:methods; D055414:Myocardial Perfusion Imaging / Q000379:methods; D011446:Prospective Studies; D015203:Reproducibility of Results; D018570:Risk Assessment; D015899:Tomography, Emission-Computed, Single-Photon / Q000191:economics / Q000379:methods
keywords: cardiac computed tomography; coronary artery calcium; single photon tomography