CCTA for evaluating acute chest pain in ED: SCCT guidance
USA: The Society of Cardiovascular Computed Tomography (SCCT) has published new guidance for physicians and hospitals alike regarding best practices and advice for use of coronary CT angiography (CCTA) for the evaluation of acute chest pain (ACP) in the emergency department.
The consensus, published in the Journal of Cardiovascular Computed Tomography, is endorsed by the North American Society for Cardiovascular Imaging (NASCI) and the American College of Radiology (ACR).
Several studies over the past decade including 8 randomized controlled trials and 5 meta-analyses, validate coronary CTA as a first-line imaging strategy for rapid triage of low-to-intermediate risk ACP in the emergency department (ED).
The document outlines the benefits of CCTA as the first-line test for ACP and provides recommendations for appropriate patient selection, preparation, protocol selection, interpretation, reporting and patient management based on clinical evidence and expert consensus.
Given below are the statements from the document:
- Coronary CTA is complementary to hs-cTn assays in the ED by improving specificity for ACS and identifying vulnerable anatomy.
- Coronary CTA combined with CT-based fractional flow reserve (FFR-CT) or stress myocardial CT perfusion (CTP) may offer a comprehensive evaluation of coronary anatomy and physiology, potentially eliminating unnecessary invasive coronary angiograms.
- High-risk plaque on coronary CTA may provide additional prognostic value beyond stenosis severity, although it remains unclear how plaque morphology should influence decision-making in the ED setting.
The document mentions a potential role for coronary CTA in select non-ST-elevation ACS patients in cases where an invasive stragey is not preferred due to clinical variables including patient preference, high bleeding risk, and vascular access issues.
The document states, "multiple professional societies including the European Society of Cardiology and the American College of Cardiology/American Heart Association endorse coronary CTA as a first-line triage strategy for ACP in the ED.
Recommendations
- Interpretation and reporting should be consistent with SCCT Guidelines.
- Coronary CTA scans should be reviewed for stenosis severity, plaque morphology, and an estimate of total coronary plaque burden.
- Ordering clinicians should be notified immediately of abnormal coronary CTA scans with severe stenosis.
- The CAD-RADS 2.0 lexicon should be incorporated into the report, with a final assessment category, modifiers, and management recommendations. CAD-RADS is a standardized reporting system for patients undergoing coronary CTA that links imaging findings with patient management recommendations.
- All coronary CTA scans from the ED should be evaluated and reported in a timely manner per local institutional policy.
- Non-coronary findings should be included in the body of the report, and clinically significant findings (i.e. pulmonary embolism, aortic dissection) should be communicated directly to the ordering clinician.
The authors wrote in their conclusion, "These recommendations were produced as an educational tool for practitioners evaluating ACP in the ED for developing systematic standards for coronary CTA based on clinical evidence and expert consensus."
"As CT technology rapidly expands in the era of artificial intelligence, promising new diagnostic and prognostic CT strategies are likely to further impact clinical management and risk stratification."
"This document serves as a framework for hospitals and emergency departments looking to implement and expand their coronary CTA programs," said Christopher Maroules, MD, FSCCT, lead author.
"With the detailed operational guidelines and best practices outlined in this document, physicians and administrators will be equipped to leverage the maximum value of this pathway, improving health outcomes for their patients, decompressing busy emergency rooms and lowering healthcare costs."
According to Maroules, the guidance is supported by data from eight randomized controlled trials and five meta-analyses validating the utility of CCTA in the emergency department.
Coronary CTA is now a recognized frontline test for acute chest pain triage, endorsed with the highest possible rating (Class I, Level of Evidence A) in the 2021 AHA/ACC Guideline for the Evaluation and Diagnosis of Chest Pain, he said.
"We've finally passed the inflection point where coronary CTA can be considered the new 'standard of care' for acute chest pain triage in patients with low-to-intermediate risk for acute coronary syndrome (ACS)."
Reference:
Maroules CD, Rybicki FJ, Ghoshhajra BB, et al. 2022 use of coronary computed tomographic angiography for patients presenting with acute chest pain to the emergency department: an expert consensus document of the Society of Cardiovascular Computed Tomography (SCCT). J Cardiovasc Comput Tomogr. 2022;Epub ahead of print.
