title: Coronary CT Angiography for Suspected ACS in the Era of High-Sensitivity Troponins: Randomized Multicenter Study.
abstract: BACKGROUND
  It is uncertain whether a diagnostic strategy supplemented by early coronary computed tomography angiography (CCTA) is superior to contemporary standard optimal care (SOC) encompassing high-sensitivity troponin assays (hs-troponins) for patients suspected of acute coronary syndrome (ACS) in the emergency department (ED).
  
  
  OBJECTIVE
  This study assessed whether a diagnostic strategy supplemented by early CCTA improves clinical effectiveness compared with contemporary SOC.
  
  
  METHODS
  In a prospective, open-label, multicenter, randomized trial, we enrolled patients presenting with symptoms suggestive of an ACS at the ED of 5 community and 2 university hospitals in the Netherlands. Exclusion criteria included the need for urgent cardiac catheterization and history of ACS or coronary revascularization. The primary endpoint was the number of patients identified with significant coronary artery disease requiring revascularization within 30 days.
  
  
  RESULTS
  The study population consisted of 500 patients, of whom 236 (47%) were women (mean age 54 ± 10 years). There was no difference in the primary endpoint (22 [9%] patients underwent coronary revascularization within 30 days in the CCTA group and 17 [7%] in the SOC group [p = 0.40]). Discharge from the ED was not more frequent after CCTA (65% vs. 59%, p = 0.16), and length of stay was similar (6.3 h in both groups; p = 0.80). The CCTA group had lower direct medical costs (€337 vs. €511, p < 0.01) and less outpatient testing after the index ED visit (10 [4%] vs. 26 [10%], p < 0.01). There was no difference in incidence of undetected ACS.
  
  
  CONCLUSIONS
  CCTA, applied early in the work-up of suspected ACS, is safe and associated with less outpatient testing and lower costs. However, in the era of hs-troponins, CCTA does not identify more patients with significant CAD requiring coronary revascularization, shorten hospital stay, or allow for more direct discharge from the ED. (Better Evaluation of Acute Chest Pain with Computed Tomography Angiography [BEACON]; NCT01413282).
authors.affiliation: Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Radiology, Erasmus University Medical Center, Rotterdam, the Netherlands. Electronic address: a.dedic@erasmusmc.nl.
authors.forename: Admir
authors.initials: A
authors.lastname: Dedic
authors.affiliation: Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Radiology, Erasmus University Medical Center, Rotterdam, the Netherlands.
authors.forename: Marisa M
authors.initials: MM
authors.lastname: Lubbers
authors.affiliation: Department of Cardiology, Amphia Ziekenhuis, Breda, the Netherlands.
authors.forename: Jeroen
authors.initials: J
authors.lastname: Schaap
authors.affiliation: Department of Cardiology, Catharina Ziekenhuis, Eindhoven, the Netherlands.
authors.forename: Jeronymus
authors.initials: J
authors.lastname: Lammers
authors.affiliation: Department of Cardiology, Canisius Wilhelmina Ziekenhuis, Nijmegen, the Netherlands.
authors.forename: Evert J
authors.initials: EJ
authors.lastname: Lamfers
authors.affiliation: Department of Cardiology, St. Antonius Ziekenhuis, Nieuwegein, the Netherlands.
authors.forename: Benno J
authors.initials: BJ
authors.lastname: Rensing
authors.affiliation: Department of Cardiology, Gelre Ziekenhuis, Apeldoorn, the Netherlands.
authors.forename: Richard L
authors.initials: RL
authors.lastname: Braam
authors.affiliation: Department of Cardiology, University Medical Center Utrecht, Utrecht, the Netherlands.
authors.forename: Hendrik M
authors.initials: HM
authors.lastname: Nathoe
authors.affiliation: Department of Cardiology, Catharina Ziekenhuis, Eindhoven, the Netherlands.
authors.forename: Johannes C
authors.initials: JC
authors.lastname: Post
authors.affiliation: Department of Cardiology, Canisius Wilhelmina Ziekenhuis, Nijmegen, the Netherlands.
authors.forename: Tim
authors.initials: T
authors.lastname: Nielen
authors.affiliation: Department of Cardiology, Amphia Ziekenhuis, Breda, the Netherlands.
authors.forename: Driek
authors.initials: D
authors.lastname: Beelen
authors.affiliation: Department of Cardiology, Gelre Ziekenhuis, Apeldoorn, the Netherlands.
authors.forename: Marie-Claire
authors.initials: MC
authors.lastname: le Cocq d'Armandville
authors.affiliation: Department of Emergency Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands.
authors.forename: Pleunie P M
authors.initials: PP
authors.lastname: Rood
authors.affiliation: Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Cardiology, Royal Perth Hospital Campus, University of Western Australia, Perth, Australia.
authors.forename: Carl J
authors.initials: CJ
authors.lastname: Schultz
authors.affiliation: Department of Radiology, Erasmus University Medical Center, Rotterdam, the Netherlands.
authors.forename: Adriaan
authors.initials: A
authors.lastname: Moelker
authors.affiliation: Department of Radiology, Erasmus University Medical Center, Rotterdam, the Netherlands.
authors.forename: Mohamed
authors.initials: M
authors.lastname: Ouhlous
authors.affiliation: Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands.
authors.forename: Eric
authors.initials: E
authors.lastname: Boersma
authors.affiliation: Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Radiology, Erasmus University Medical Center, Rotterdam, the Netherlands.
authors.forename: Koen
authors.initials: K
authors.lastname: Nieman
mesh_terms: D054058:Acute Coronary Syndrome / Q000097:blood* / Q000000981:diagnostic imaging* / Q000628:therapy; D000368:Aged; D017023:Coronary Angiography; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D009204:Myocardial Revascularization; D009426:Netherlands; D011446:Prospective Studies; D014057:Tomography, X-Ray Computed; D014336:Troponin / Q000097:blood*
chemical_list: D014336:Troponin
keywords: chest pain; coronary artery disease; diagnosis; emergency department