This study aims to evaluate whether an evaluation strategy incorporating early cardiac CT angiography (CCTA) improves clinical decision making compared to standard evaluation for patients presenting to the emergency department with acute chest pain suggestive of acute coronary syndrome (ACS) but without diagnostic ECG changes or positive troponin. The study is a randomized controlled trial that assigns eligible patients aged 40-74 years to either the CCTA or standard evaluation groups. The primary outcome is length of hospital stay, with secondary outcomes including rates of direct emergency department discharge, costs, radiation exposure, time to diagnosis, and safety/adverse events.

2. Background
 Chest Pain due to ACS is one of the
most common presentations to ER
 Current strategies to R/O ACS are
inefficient – Unnecessary admissions
and ER overcrowded
 Despite low threshold to admit patients
up to 2% of patients Discharged with
missed ACS

3. Cardiac CT Angiography
 Previous studies Showed that CCTA has
Accurate Noninvasive Detection of
significant CAD with High NPV during
the index hospitalization and the
occurrence of major adverse
cardiovascular events over the next 2
years
Hollander JE, Chang AM, Shofer FS, et al. One-year outcomes following coronary computerized tomographic angiography for evaluation of
emergency department patients with potential acute coronary syndrome. Acad Emerg Med 2009;16:693-8
Schlett CL,, et al.
Prognostic value of CT angiography for major adverse cardiac events in patients with acute chest pain from the emergency department: 2-year
outcomes of the ROMICAT trial. JACC Cardiovasc Imaging 2011;4:481-91

4. The hypothesis
 An evaluation strategy incorporating
early CCTA will improve the
effectiveness of clinical decision making
as compared to a Standard ED
Evaluation in Patients with acute chest
pain suggestive of ACS
 Study Type : Diagnostic cohort
 Study Design : RCT

5. P  40 to 74 years of age with symptoms
suggestive of ACS but without ischemic
ECG Changes or an initial positive
troponin test
I  CCTA
C  Standard Evaluation
O  Primary End Point, length of stay in the
hospital

6. Secondary Endpoints
 Rates of direct discharge from the ED
 Cumulative costs
 Cumulative radiation exposure
 Time to diagnosis
 Safety variables (Periprocedural
complications, undetected acute coronary
syndrome within 72 hrs after discharge,
MACE at 28 days)
 Utilization of other diagnostic testing
 Resource utilization

7. Inclusion Criteria
 Patients with > 5 min of Chest Pain or
Angina Equivelant within the past 24
hours
 40 to 74 years of age
 sinus rhythm Patients
 Patient must be able to Hold Breath >10
seconds
 Patient must be able to sign an informed
consent

8. Exclusion Criteria
 History of known coronary artery disease !!
 New diagnostic ischemic changes on the
initial ECG
 Initial troponin level in excess of the 99th
percentile of the local assay
 Impaired renal function
 Hemodynamic or clinical instability,
 Known allergy to an iodinated contrast
agent
 Body Mass Index greater than 40
 Currently symptomatic asthma.

10. Was the assignment of
patients to treatments
randomized?
 Yes, randomly assigned in a 1:1 ratio

11. Was the randomization
Concealed ?
 No

12. Were the groups similar at
the start of the trial?
 Yes

15. Aside from the allocated
treatment were groups treated
equally?
 Yes, and both arms were Followed up for 28
Days

16. Were all patients who entered
the trial accounted for?
 No, Almost 1% lost the Follow up

18. Were Patients analysed in the
groups to which they were
randomized?
 Yes, with the use of intention to treat analysis

19. Were measures objective
?
 Yes, they were objectives (Length of
stay and cost and Radiation Exposure)

20. Were the patients and
clinicians kept “blind” to
which treatment was being
received?
 No, it wasn’t Blind

21. Results

25. Summary
 CCTA has:
 High Diagnostic Accuracy
 Less Time to Dx
 More Direct Discharge From ER
 Reduce Length of stay
 More cost !!
 More Radiation

26. Will the results help me in
caring for my patient?
 Yes, But to a limited group of patients

27. Applicability of the study
 Patients were recruited at weekday
daytime hours
 Patients with History of
 Known coronary artery disease
 Hemodynamic or clinical instability
 Impaired renal function
 Limited age group
were excluded
 We can Apply CCTA in our institution