title: Coronary CT Angiography Versus Standard Emergency Department Evaluation for Acute Chest Pain and Diabetic Patients: Is There Benefit With Early Coronary CT Angiography? Results of the Randomized Comparative Effectiveness ROMICAT II Trial.
abstract: BACKGROUND
  Cardiac computed tomography angiography (CCTA) reduces emergency department length of stay compared with standard evaluation in patients with low- and intermediate-risk acute chest pain. Whether diabetic patients have similar benefits is unknown.
  
  
  RESULTS
  In this prespecified analysis of the Rule Out Myocardial Ischemia/Infarction by Computer Assisted Tomography (ROMICAT II) multicenter trial, we randomized 1000 patients (17% diabetic) with symptoms suggestive of acute coronary syndrome to CCTA or standard evaluation. The rate of acute coronary syndrome was 8% in both diabetic and nondiabetic patients (P=1.0). Length of stay was unaffected by the CCTA strategy for diabetic patients (23.9 versus 27.2 hours, P=0.86) but was reduced for nondiabetic patients compared with standard evaluation (8.4 versus 26.5 hours, P<0.0001; P interaction=0.004). CCTA resulted in 3-fold more direct emergency department discharge in both groups (each P≤0.0001, P interaction=0.27). No difference in hospital admissions was seen between the 2 strategies in diabetic and nondiabetic patients (P interaction=0.09). Both groups had more downstream testing and higher radiation doses with CCTA, but these were highest in diabetic patients (all P interaction≤0.04). Diabetic patients had fewer normal CCTAs than nondiabetic patients (32% versus 50%, P=0.003) and similar normalcy rates with standard evaluation (P=0.70). Notably, 66% of diabetic patients had no or mild stenosis by CCTA with short length of stay comparable to that of nondiabetic patients (P=0.34), whereas those with >50% stenosis had a high prevalence of acute coronary syndrome, invasive coronary angiography, and revascularization.
  
  
  CONCLUSIONS
  Knowledge of coronary anatomy with CCTA is beneficial for diabetic patients and can discriminate between lower risk patients with no or little coronary artery disease who can be discharged immediately and higher risk patients with moderate to severe disease who warrant further workup.
  
  
  BACKGROUND
  URL: https://www.clinicaltrials.gov/. Unique identifier: NCT01084239.
authors.affiliation: Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital and Weill Cornell Medical College, New York, NY.
authors.forename: Quynh A
authors.initials: QA
authors.lastname: Truong
authors.affiliation: Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital and Weill Cornell Medical College, New York, NY.
authors.forename: Joshua
authors.initials: J
authors.lastname: Schulman-Marcus
authors.affiliation: Massachusetts General Hospital Biostatistics Center, Harvard Medical School, Boston, MA.
authors.forename: Pearl
authors.initials: P
authors.lastname: Zakroysky
authors.affiliation: Kaiser Permanente Fontana Medical Center, Fontana, CA.
authors.forename: Eric T
authors.initials: ET
authors.lastname: Chou
authors.affiliation: Emergency Department, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
authors.forename: John T
authors.initials: JT
authors.lastname: Nagurney
authors.affiliation: Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD.
authors.forename: Jerome L
authors.initials: JL
authors.lastname: Fleg
authors.affiliation: Massachusetts General Hospital Biostatistics Center, Harvard Medical School, Boston, MA.
authors.forename: David A
authors.initials: DA
authors.lastname: Schoenfeld
authors.affiliation: Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA.
authors.forename: James E
authors.initials: JE
authors.lastname: Udelson
authors.affiliation: Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
authors.forename: Udo
authors.initials: U
authors.lastname: Hoffmann
authors.affiliation: Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO woodardp@mir.wustl.edu.
authors.forename: Pamela K
authors.initials: PK
authors.lastname: Woodard
mesh_terms: D054058:Acute Coronary Syndrome / Q000150:complications / Q000000981:diagnostic imaging*; D000328:Adult; D000368:Aged; D000787:Angina Pectoris / Q000000981:diagnostic imaging* / Q000209:etiology; D016507:Cardiology Service, Hospital; D017023:Coronary Angiography / Q000379:methods*; D003324:Coronary Artery Disease / Q000150:complications / Q000000981:diagnostic imaging*; D003925:Diabetic Angiopathies / Q000150:complications / Q000000981:diagnostic imaging*; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010351:Patient Discharge; D011237:Predictive Value of Tests; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D014481:United States
keywords: acute coronary syndrome; cardiac computed tomography; chest pain diagnosis; diabetes mellitus; emergency department