title: Use of Coronary Computed Tomographic Angiography Findings to Modify Statin and Aspirin Prescription in Patients With Acute Chest Pain.
abstract: Coronary CT angiography (CCTA) is used in patients with low-intermediate chest pain presenting to the emergency department for its reliability in excluding acute coronary syndrome (ACS). However, its influence on medication modification in this setting is unclear. We sought to determine whether knowledge of CCTA-based coronary artery disease (CAD) was associated with change in statin and aspirin prescription. We used the CCTA arm of the Rule Out Myocardial Infarction using Computed Angiographic Tomography II multicenter, randomized control trial (R-II) and comparison cohort from the observational Rule Out Myocardial Infarction using Computed Angiographic Tomography I cohort (R-I). In R-II, subjects were randomly assigned to CCTA to guide decision making, whereas in R-I patients underwent CCTA with results blinded to caregivers and managed according to standard care. Our final cohort consisted of 277 subjects from R-I and 370 from R-II. ACS rate was similar (6.9% vs 6.2% respectively, p = 0.75). For subjects with CCTA-detected obstructive CAD without ACS, initiation of statin was significantly greater after disclosure of CCTA results (0% in R-I vs 20% in R-II, p = 0.009). Conversely, for subjects without CCTA-detected CAD, aspirin prescription was lower with disclosure of CCTA results (16% in R-I vs 4.8% in R-II, p = 0.001). However, only 68% of subjects in R-II with obstructive CAD were discharged on statin and 65% on aspirin. In conclusion, physician knowledge of CCTA results leads to improved alignment of aspirin and statin with the presence and severity of CAD although still many patients with CCTA-detected CAD are not discharged on aspirin or statin. Our findings suggest opportunity for practice improvement when CCTA is performed in the emergency department.
authors.affiliation: Division of Cardiology, Department of Radiology, Cardiac Magnetic Resonance, Positron Emission Tomography, and Computed Tomography Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts. Electronic address: amit.pursnani@gmail.com.
authors.forename: Amit
authors.initials: A
authors.lastname: Pursnani
authors.affiliation: Division of Cardiology, Department of Radiology, Cardiac Magnetic Resonance, Positron Emission Tomography, and Computed Tomography Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Csilla
authors.initials: C
authors.lastname: Celeng
authors.affiliation: Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany.
authors.forename: Christopher L
authors.initials: CL
authors.lastname: Schlett
authors.affiliation: Division of Cardiology, Department of Radiology, Cardiac Magnetic Resonance, Positron Emission Tomography, and Computed Tomography Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Thomas
authors.initials: T
authors.lastname: Mayrhofer
authors.affiliation: Massachusetts General Hospital Biostatistics Center, Harvard Medical School, Boston, Massachusetts.
authors.forename: Pearl
authors.initials: P
authors.lastname: Zakroysky
authors.affiliation: Massachusetts General Hospital Biostatistics Center, Harvard Medical School, Boston, Massachusetts.
authors.forename: Hang
authors.initials: H
authors.lastname: Lee
authors.affiliation: Division of Cardiology, Department of Radiology, Cardiac Magnetic Resonance, Positron Emission Tomography, and Computed Tomography Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Maros
authors.initials: M
authors.lastname: Ferencik
authors.affiliation: Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland.
authors.forename: Jerome L
authors.initials: JL
authors.lastname: Fleg
authors.affiliation: Department of Clinical Radiology, Klinikum Grosshadern, Ludwig-Maximilians University, Munich, Germany.
authors.forename: Fabian
authors.initials: F
authors.lastname: Bamberg
authors.affiliation: Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Stephen D
authors.initials: SD
authors.lastname: Wiviott
authors.affiliation: Division of Cardiology, Department of Radiology, Cardiac Magnetic Resonance, Positron Emission Tomography, and Computed Tomography Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Quynh A
authors.initials: QA
authors.lastname: Truong
authors.affiliation: Division of Cardiology and the Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts.
authors.forename: James E
authors.initials: JE
authors.lastname: Udelson
authors.affiliation: Division of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: John T
authors.initials: JT
authors.lastname: Nagurney
authors.affiliation: Division of Cardiology, Department of Radiology, Cardiac Magnetic Resonance, Positron Emission Tomography, and Computed Tomography Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
authors.forename: Udo
authors.initials: U
authors.lastname: Hoffmann
mesh_terms: D054058:Acute Coronary Syndrome / Q000150:complications / Q000000981:diagnostic imaging* / Q000517:prevention & control; D000328:Adult; D000368:Aged; D001241:Aspirin / Q000008:administration & dosage*; D002637:Chest Pain / Q000000981:diagnostic imaging* / Q000209:etiology; D017023:Coronary Angiography / Q000379:methods*; D003657:Decision Making; D003937:Diagnosis, Differential; D004305:Dose-Response Relationship, Drug; D011307:Drug Prescriptions / Q000706:statistics & numerical data*; D004359:Drug Therapy, Combination; D005260:Female; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000008:administration & dosage*; D008297:Male; D008875:Middle Aged; D061330:Multidetector Computed Tomography / Q000379:methods*; D010975:Platelet Aggregation Inhibitors / Q000008:administration & dosage; D011237:Predictive Value of Tests; D015203:Reproducibility of Results
chemical_list: D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors; D010975:Platelet Aggregation Inhibitors; D001241:Aspirin