CCTA safe, less expensive option for excluding acute coronary syndrome in patients with chest pain

"The findings are good news for both patients and clinicians," the researchers wrote in their study. "Our review reassures health care decision-makers that coronary CT angiography is a safe strategy to rule out ACS in adult patients experiencing ACP as pooled evidence shows similar incidence of mortality and myocardial infarction between CCTA and standard of care arms."

Acute chest pain is the second most frequent condition for which patients present to the emergency department. Some of these patients will have acute coronary syndrome but most do not, making it important that a method exists to rule out disease. The standard of care in this regard includes electrocardiography, observation, and stress testing. However, all of these methods raise healthcare costs and take significant time.

Compared to the standard of care methods, CCTA may offer key benefits. Fernando U. Kay, University of Pennsylvania, Philadelphia, PA, and colleagues aimed to compare the effectiveness of coronary CT angiography and standard of care (SOC) in the evaluation of acute chest pain.

For this purpose, the researchers systematically searched multiple electronic databases, with the most recent search conducted on October 31, 2022. Based on the pretest probability for acute coronary syndrome, studies were stratified into two groups; group 1 with predominantly low-to-intermediate risk versus group 2 with high risk. A meta-regression analysis was conducted using the type of SOC used, participant risk, and the use or non-use of high-sensitivity troponins as independent variables.

22 randomized controlled trials comprising 9379 participants (4956 assigned to CCTA arms and 4423 to SOC arms) were included in the final analysis.

The researchers reported the following findings:

• There was a 14% reduction in the length of stay and a 17% reduction in immediate costs for the CCTA arm compared with the SOC arm.
• In group 1, the length of stay was 17% shorter and costs were 21% lower using CCTA.
• There was no evidence of differences in referrals to invasive coronary angiography, myocardial infarction, mortality, rate of hospitalization, further stress testing, or readmissions between CCTA and SOC arms.
• There were more revascularizations (relative risk, 1.45) and medication changes (relative risk, 1.33) in participants with low-to-intermediate acute coronary syndrome risk and increased radiation exposure in high-risk participants (mean difference, 7.24 mSv) in the CCTA arm compared with the SOC arm.
• The meta-regression analysis found significant differences between CCTA and SOC arms for the rate of hospitalization, further stress testing, and medication changes depending on the type of SOC.

"Our findings support the recommendations of the current guideline for the use of CCTA as a rapid, safe, and less expensive short-term strategy to exclude ACS in low- to intermediate-risk patients presenting with ACP," the researchers concluded.

Reference:

Comparative Effectiveness of Coronary CT Angiography and Standard of Care for Evaluating Acute Chest Pain: A Living Systematic Review and Meta-Analysis. Maurício F. Barbosa, Arzu Canan, Yin Xi, Harold Litt, Deborah B. Diercks, Suhny Abbara, and Fernando U. Kay. Radiology: Cardiothoracic Imaging 2023 5:4