Original title: Outcomes After Coronary Computed Tomography Angiography in the Emergency Department. A Systematic Review and Meta-Analysis of Randomized, Controlled Trials. Reference: Edward Hulten et al. J Am Coll Cardiol 2013. Article in press
Chest pain is the second most common cause for visiting an emergency department. In all consultations, only few are finally acute coronary syndromes, for this purpose several strategies have been tested to improve efficiency and reduce costs. Most centres choose to hospitalize patients or send them to a pain unit which prevents inadvertent discharge of a patient having an acute coronary syndrome, this choice consume and extend stay and increases costs.
The aim of this meta-analysis was to evaluate randomized studies comparing the use of multislice computed tomography coronary angiography versus standard strategy for the stratification risk of chest pain in the emergency department. We analysed four randomized studies with a total of 3266 patients (1869 patients in CT branch and 1397 standard strategy) consulting for low-risk chest pain (ECG with out ischemic changes and negative biomarkers). Baseline characteristics were similar between groups.
CT branch patients were more frequently refer to catheterization (8.4% versus 6.3%, p = 0.030) and received revascularization more frequently either by angioplasty or surgery (4.6% versus 2.6%, p = 0.004). The absolute increase was 21 diagnostic catheterizations and 20 revascularization procedures per 1000 patients. All studies reported a significant decrease of hospital stay and costs with the use of CT.
Conclusion:
Stratification of low-risk chest pain in the emergency department with multislice CT was safe, reducing costs and hospital stay. Was associated with an increased incidence of catheterizations and revascularization compared with the standard strategy.
Commentary:
Low event rate in both groups (no deaths and few strokes) prevents to take conclusions on clinical end points. It will take many more large studies, given the low risk of the population, to see if CT scan and subsequent greater revascularization, decrease events. Beyond the foregoing, the fact of being a safe strategy and show a lower cost justifies its use.
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