Coronary Computed Tomography Angiography Versus Stress Echocardiography in Acute Chest Pain: A Randomized Controlled Trial

JACC Cardiovasc Imaging. 2018 Sep;11(9):1288-1297. doi: 10.1016/j.jcmg.2018.03.024. Epub 2018 Jun 13.

Abstract

Objectives: This study sought to compare early emergency department (ED) use of coronary computed tomography angiography (CTA) and stress echocardiography (SE) head-to-head.

Background: Coronary CTA has been promoted as the early ED chest pain triage imaging method of choice, whereas SE is often overlooked in this setting and involves no ionizing radiation.

Methods: The authors randomized 400 consecutive low- to intermediate-risk ED acute chest pain patients without known coronary artery disease and a negative initial serum troponin level to immediate coronary CTA (n = 201) or SE (n = 199). The primary endpoint was hospitalization rate. Secondary endpoints were ED and hospital length of stay. Safety endpoints included cardiovascular events and radiation exposure.

Results: Mean patient age was 55 years, with 43% women and predominantly ethnic minorities (46% Hispanics, 32% African Americans). Thirty-nine coronary CTA patients (19%) and 22 SE patients (11%) were hospitalized at presentation (difference 8%; 95% confidence interval: 1% to 15%; p = 0.026). Median ED length of stay for discharged patients was 5.4 h (interquartile range [IQR]: 4.2 to 6.4 h) for coronary CTA and 4.7 h (IQR: 3.5 to 6.0 h) for SE (p < 0.001). Median hospital length of stay was 58 h (IQR: 50 to 102 h) for coronary CTA and 34 h (IQR: 31 to 54 h) for SE (p = 0.002). There were 11 and 7 major adverse cardiovascular events for coronary CTA and SE, respectively (p = 0.47), over a median 24 months of follow-up. Median/mean complete initial work-up radiation exposure was 6.5/7.7 mSv for coronary CTA and 0/0.96 mSv for SE (p < 0.001).

Conclusions: The use of SE resulted in the hospitalization of a smaller proportion of patients with a shorter length of stay than coronary CTA and was safe. SE should be considered an appropriate option for ED chest pain triage (Stress Echocardiography and Heart Computed Tomography [CT] Scan in Emergency Department Patients With Chest Pain; NCT01384448).

Keywords: acute chest pain; admission rate; coronary CT angiography; emergency department; length of stay; stress echocardiography.

Publication types

  • Comparative Study
  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Angina Pectoris / diagnostic imaging*
  • Angina Pectoris / physiopathology
  • Angina Pectoris / therapy*
  • Clinical Decision-Making
  • Comparative Effectiveness Research
  • Computed Tomography Angiography*
  • Coronary Angiography / methods*
  • Coronary Artery Disease / diagnostic imaging*
  • Coronary Artery Disease / physiopathology
  • Coronary Artery Disease / therapy
  • Echocardiography, Stress*
  • Emergency Service, Hospital
  • Female
  • Humans
  • Length of Stay
  • Male
  • Middle Aged
  • Multidetector Computed Tomography*
  • Patient Admission
  • Patient Selection
  • Predictive Value of Tests
  • Radiation Dosage
  • Radiation Exposure
  • Treatment Outcome
  • Triage

Associated data

  • ClinicalTrials.gov/NCT01384448