Risk-reward: Knowing when to use coronary CT angiography

Every year, eight million Americans visit emergency departments with acute chest pain. Coronary CT angiography (CCTA) is commonly used to triage patients with acute coronary syndrome (ACS).

In a recent article in Journal of the American College of Radiology, a team of researchers looked at when CCTA best served patients with acute chest pain, urging EDs to avoid use on high-risk patients according to JAMA’s Choosing Wisely recommendations.

Led by Pamela Woodard, MD, professor of radiology and biomedical engineering at Washington University in St. Louis, researchers also cautioned against ordering CCTA for those on the other side of the risk spectrum.

“It is equally important not to overuse CCTA imaging in very low-risk patients, especially when the chest pain is suggestive of other non-cardiovascular etiologies,” Woodard et al. wrote. “In these situations, for some patients, either no imaging or only a standard chest radiograph is necessary.”

The paper cited three trials as supportive evidence for such protocols in harnessing CCTA.

1. The first was a multicenter trial that compared CCTA to myocardial perfusion imaging (MPI). Results included a 54 percent reduction in time to diagnosis in CCTA patients after six months. Costs were 38 percent lower for patients undergoing CCTA compared to MPI patients.

2. The second study examined low- to intermediate-risk acute chest pain patients. Compared to patients receiving usual care, CCTA patients had a higher rate of ED discharge (50 percent vs. 23 percent), a shorter length of stay (18 hours vs. 24.8 hours) and a higher rate of detection (9 percent vs. 3.5 percent).

3. The final study found those who received CCTA had shorter stays by 7.6 hours and more were discharged directly from the ED (47 percent vs. 12 percent).

The work is a part of efforts by the Radiology Support, Communication and Alignment Network (R-SCAN), a CMS-sponsored effort to improve imaging appropriateness and streamline ordering.