MIA 2012: Hoffmann U et al. Coronary CT angiography versus standard evaluation in acute chest pain. N Engl J Med. 2012 Jul 26;367(4):299-308.

Bottom Line ¹

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

MIA 2012 = Most Interesting Articles series of 2012

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