Testing Strategies to Rule Out Acute Coronary Syndromes: Which Is Most Efficient?

Harlan M. Krumholz, MD, SM

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Abstract and Introduction

Abstract

Compared with standard evaluation, early CCTA shortened hospital stay but increased subsequent testing and radiation exposure with no reduction in overall cost of care.

Introduction

Advances in technology have expanded the choices available for evaluating patients with acute chest pain but have also generated much controversy about the ideal testing strategy. In the ROMICAT-II trial, sponsored by the National Heart, Lung, and Blood Institute, investigators compared a strategy of early contrast-enhanced coronary computed tomographic angiography (CCTA) with standard emergency-department evaluation of adults with a suspected acute coronary syndrome (ACS) with respect to length of hospital stay, subsequent testing, cost, and radiation exposure.

Of 1273 patients assessed for eligibility, 1000 were randomized (mean age, 54; almost 50% women). Average hospital stay was 7.6 hours shorter in the CCTA group than in the standard-care group (P<0.001). In the 8% of patients with ACS, the length of hospital stay was similar in both groups. Clinical adverse events were rare and similar in both groups. The CCTA group underwent more diagnostic testing than the standard-evaluation group (≥2 tests, 23% vs. 11%; P<0.001). Mean cumulative radiation exposure was also higher in the CCTA group (13.9 mSV vs. 4.7 mSV; P<0.001). In 649 patients with detailed cost data available, the overall cost of the two strategies was similar.

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