Coronary Computed Tomography for Systemic Triage of Acute Chest Pain Patients to Treatment - CT-STAT

Sep 19, 2011
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Author/Summarized by Author:
Anthony A. Bavry, MD,MPH,FACC
Summary Reviewer:
Deepak L. Bhatt, MD, MPH, MBA, FACC
Trial Sponsor:
Bayer Pharmaceuticals
Date Presented:
01/01/2009
Date Published:
01/01/2011
Date Updated:
09/19/2011
Original Posted Date:
09/19/2011
References

Description:

The goal of this trial was to compare coronary computed tomography (CT) angiography with myocardial perfusion imaging (MPI) among low-risk patients with acute chest pain.

Hypothesis:

Coronary CT angiography would result in reduced time to diagnosis and cost to diagnosis.

Study Design

  • Randomized
  • Parallel

Patients Enrolled: 701

Patient Populations:

  • Low-risk acute chest pain patients (≥25 years) defined as TIMI risk <4 and normal initial electrocardiogram and cardiac enzymes

Exclusions:

  • Known coronary artery disease
  • Known cardiomyopathy
  • Contraindication to iodinated contrast and/or beta-blocking drugs
  • Atrial fibrillation or markedly irregular rhythm
  • Body mass index (≥39 kg/m2)
  • Elevated serum creatinine (≥1.5 mg/dl)
  • CT imaging or contrast administration in the past 48 hours

Primary Endpoints:

  • Diagnostic efficiency defined as the time to diagnosis and cost to diagnosis

Secondary Endpoints:

  • MACE at 6 months

Drug/Procedures Used:

Low-risk patients with chest pain were randomized to coronary CT angiography (n = 361) versus risk assessment with MPI (n = 338).

Principal Findings:

Overall, 699 patients were randomized. The mean age was 50 years, 55% were women, mean body mass index was 28 kg/m2, and 6% had diabetes. The proportion of patients that underwent invasive coronary angiography during the index hospitalization was 6.6% with coronary CT angiography versus 6.2% with standard stress testing (p = NS).

In the coronary CT angiography group, no significant stenosis was detected in 82%, at least one severe stenosis (>70%) in 3.6%, and moderate stenosis (25-70%) in 10.2%. Stress testing was additionally required in 37 patients. Ultimately, nine percutaneous coronary intervention (PCI) and four coronary artery bypass grafting (CABG) procedures were performed. No acute coronary syndrome occurred when there was no evidence of severe obstruction.

In the MPI group, a normal stress test was present in 90%, and abnormal or equivocal in 10%, which ultimately resulted in eight PCIs and no CABG.

The time to make a diagnosis was 2.9 hours in the CT angiography group versus 6.3 hours in the MPI group (p < 0.0001) and total costs were $2,137 versus $3,458 (p < 0.0001), respectively. Major adverse cardiac events (MACE) at 6 months in patients with a normal index test were 0.8% versus 0.4% (p = 0.29), respectively.

Interpretation:

Among low-risk patients with acute chest pain, coronary CT angiography ruled out severe disease in 82%. This strategy decreased the time to diagnosis and costs with making a diagnosis. Adverse outcomes were similar between the groups. Future studies are needed to address the long-term safety of this diagnostic modality.

References:

Goldstein JA, Chinnaiyan KA, Abidovet A, al. The CT-STAT (Coronary Computed Tomographic Angiography for Systematic Triage of Acute Chest Pain Patients to Treatment) Trial. J Am Coll Cardiol 2011;58:1414-22.

Presented by Dr. James Goldstein at the American Heart Association Scientific Sessions, Orlando, FL, November 18, 2009.

Keywords: Myocardial Perfusion Imaging, Acute Coronary Syndrome, Constriction, Pathologic, Electrocardiography, Percutaneous Coronary Intervention, Body Mass Index, Coronary Angiography, Chest Pain, Tomography, Risk Assessment, Coronary Artery Bypass, Diabetes Mellitus, Exercise Test


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