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.

Jan 02, 13
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.

coronary_ct-angiogram1Bottom Line 1

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

MIA 2012 = Most Interesting Articles series of 2012

1.
Hoffmann U, Truong Q, Schoenfeld D, et al. Coronary CT angiography versus standard evaluation in acute chest pain. N Engl J Med. 2012;367(4):299-308. [PubMed]

Author information

Michelle Lin, MD

ALiEM Founder and CEO
Professor and Digital Innovation Lab Director
Department of Emergency Medicine
University of California, San Francisco

The post 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. appeared first on ALiEM.

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