Coronary computed tomographic angiography in the emergency room: state of the art

Abstract

Chest pain is a common complaint in the emergency department often necessitating testing to exclude underlying obstructive coronary artery disease. While the traditional evaluation of patients with suspected acute coronary syndrome often consists of serial electrocardiograms and cardiac biomarkers, followed by selective use of stress testing for further risk stratification, this approach is costly and inefficient. Recently, coronary computed tomographic angiography (CTA) has offered an alternative approach with a high sensitivity and negative predictive value to exclude obstructive coronary artery disease that can rapidly identify patients with low rates of downstream major adverse cardiac events. In this review, the authors provide an overview of available data on the use of CTA for evaluating acute chest pain, while emphasizing its advantages and disadvantages compared to existing strategies. In addition, we provide a suggested algorithm to identify how CTA can be incorporated into the evaluation of acute chest pain and discuss tips for successful implementation of CTA in the emergency department.

Keywords::

• acute coronary syndrome
• cardiovascular risk
• chest pain
• computed tomographic angiography
• coronary artery disease
• emergency department
• major adverse cardiac events
• resource utilization
• risk stratification
• standard of care
• usual care

Acknowledgements

The views expressed here are those of the authors only and are not to be construed as those of the Department of the Defense or the US Government.

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• Chest pain is a common complaint in the emergency department (ED), where existing strategies rely on inefficient observation and selective functional testing to exclude acute coronary syndrome (ACS).

• Missed ACS remains a leading cause of malpractice litigation in the USA conferring high morbidity and mortality.

• Coronary computed tomographic angiography (CTA) is a reasonable alternative to usual care to exclude obstructive coronary artery disease and ACS in low–intermediate risk patients with acute chest pain by current guidelines.

• Multiple prospective randomized trials have demonstrated the ability of CTA to safely exclude ACS, as patients with normal CTA or minimal coronary artery disease have no (or very low) rates of early downstream major adverse cardiac events.

• The use of CTA has been shown to decrease ED length of stay and has the potential to lower cost for most patient populations evaluated with this test.

• Limitations of CTA include a low positive predictive value for detecting ischemia. In comparison to usual care, CTA has the potential to increase invasive coronary angiography and coronary revascularizations.

• Effective implementation of CTA in the ED relies on a strong collaboration between providers, appropriate patient selection and preparation and a clear protocol to provide high-quality diagnostic images.

• Significant advancements in CTA technologies have improved both image quality and patient safety.

• Ongoing studies and long-term follow-up are needed to clarify the relative cost–effectiveness and outcomes in patients undergoing CTA versus usual care with attention to image-guided therapies, long-term outcomes and downstream resource utilization.

Notes