Clinical Health Updates

Multislice CT is safe and efficient for evaluation of low-risk chest pain

Clinical Question:
Is an algorithm using multi-slice coronary computed tomography a safe and effective diagnostic approach for patients with acute chest pain?

Bottom Line:
Multi-slice coronary computed tomography (MSCT) effectively diagnoses or excludes coronary disease as the cause of acute chest pain in the majority of patients, reducing time to final diagnosis.

Reference:
Goldstein JA, Gallagher MJ, O’Neill WW, et al. A randomized controlled trial of multi-slice coronary computed tomography for evaluation of acute chest pain. J Amer Coll Cardiol 2007;49:863-871.

Study Design:
Randomized controlled trial (nonblinded)

Synopsis:
The authors ompared the safety, diagnostic efficacy, and efficiency of multi-slice computed tomography (MSCT) with standard diagnostic evaluation of low-risk acute chest pain patients. Over 1 million patients have emergency center evaluations for acute chest pain annually, at an estimated diagnostic cost of over $10 billion. Multi-slice computed tomography has a high negative predictive value for exclusion of coronary artery stenoses. So what they did, they randomized patients to MSCT (n = 99) versus SOC (n = 98) protocols. The MSCT patients with minimal disease were discharged; those with stenosis >70% underwent catheterization, whereas cases with intermediate lesions or non-diagnostic scans underwent stress testing. Outcomes included: safety (freedom from major adverse events over 6 months), diagnostic efficacy (clinically correct and definitive diagnosis), as well as time and cost of care. Both approaches were completely (100%) safe. The MSCT alone immediately excluded or identified coronary disease as the source of chest pain in 75% of patients, including 67 with normal coronary arteries and 8 with severe disease referred for invasive evaluation. The remaining 25% of patients required stress testing, owing to intermediate severity lesions or non-diagnostic scans. During the index visit, MSCT evaluation reduced diagnostic time compared with SOC (3.4 h vs. 15.0 h, p < 0.001) and lowered costs (1,586 dollars vs. 1,872 dollars, p < 0.001). Importantly, MSCT patients required fewer repeat evaluations for recurrent chest pain (MSCT, 2 of 99 (2.0%) patients vs. SOC, 7 of 99 (7%) patients; p = 0.10).