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MIA 2012: Hoffmann U et al. Coronary CT angiography versus standard evaluation in acute chest pain. N Engl J Med. 2012 Jul 26;36

Posted Jan 01 2013 4:19pm

Bottom Line
ROMICAT-II study: Coronary CT angiography (CCTA) is a safe and faster diagnostic strategy than the standard evaluation of low-to-intermediate risk chest pain patients.  CCTA, however, results in higher radiation exposure and more downstream testing. 

Why It’s Important for Emergency Medicine:
  • While the mantra in medicine is to “Do no harm”, the trend in Emergency Medicine seems simply just “Do more”. 
  • It should come as no surprise that we can get a CT scan faster than a stress test. And as well, it should be of no surprise that patients randomized to the CCTA arm are dispositioned sooner than patient evaluated by the “standard” method (which meant a stress test in 74%).  
  • The interesting point in this study (and other studies before this) is that neitherCCTA nor stress test mattered; less than 1% of the entire cohort had a myocardial infarction, and no one died!  So why can’t we sensibly defer to outpatient follow-up within a few weeks?
  • It’s time we go back to another truism: Less is more.
Major Points
  • Patients who received CCTA went home 7.6 hrs sooner than patients evaluated traditionally (23.2 hrs v 30.8 hrs). 
  • More CCTA patients were discharged directly from the ED (47% v 12%).
  • CCTA patients underwent more tests (≥ 2 tests, 23% v 11%).
  • Cumulative radiation exposure higher in CCTA (13.9 mSV v 4.7 mSV)
  • Costs were about the same.
Design
  • Randomized-controlled trial; 1000 patients, 9 hospitals
Criticisms:
  • As the editorial accompanying the original article asked, is any test needed at all?
  • Average age of participants was 54 years, which is likely too young of a CAD cohort, and just young enough to have future radiation exposure problems.           
  • Patients were only enrolled during weekday hours; costs and time would increase during nights and weekends.
Reviewed by V Nguyen


Reference:
Hoffmann U, Truong QA, Schoenfeld DA, Chou ET, Woodard PK, Nagurney JT, Pope JH, Hauser TH, White CS, Weiner SG, Kalanjian S, Mullins ME, Mikati I, Peacock WF, Zakroysky P, Hayden D, Goehler A, Lee H, Gazelle GS, Wiviott SD, Fleg JL, Udelson JE; ROMICAT-II Investigators. Coronary CT angiography versus standard evaluation in acute chest pain. N Engl J Med. 2012 Jul 26;367(4):299-308. Pubmed

MIA 2012  = Most Interesting Articles series of 2012
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