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Coronary CTA Versus Stress Echocardiography in Acute Chest Pain
Study Questions:
Which diagnostic test, coronary computed tomography angiography (CTA) or stress echocardiography, is more efficient in evaluating low- to intermediate-risk patients with chest pain in the emergency department?
Methods:
Emergency department patients presenting with acute chest pain categorized as low- to intermediate-risk were randomly assigned to either early coronary CTA or early stress echocardiography. All patients met prespecified criteria and clinically required noninvasive imaging for subsequent triage. Endpoints were rate of hospitalization (primary) and length of stay (secondary); safety outcomes, clinical resource utilization, radiation exposure, and subjective patient experiences were also assessed.
Results:
Of 400 patients randomized at Montefiore Medical Center, 201 were assigned to coronary CTA and 199 to stress echocardiography. Patients had resolution of chest pain and negative serum troponin at least 8 hours after onset of symptoms. Patients were excluded for evidence of myocardial infarction or ischemia on electrocardiogram, hemodynamic instability, crescendo or persistent chest pain, contraindications to coronary CTA or stress echocardiography, or prior coronary CTA, stress echocardiography, or cardiac catheterization within the previous 6 months. Patients presented between August 2011 and January 2016. Mean patient age was 55.0 years + 9.7 years, with 42.5% female and 87.3% ethnic minorities. A minimum of 1 year of follow-up was completed in 97%. Outcomes were assessed by intention to treat. Coronary CTA was performed on 189 of 201 patients, and stress echocardiography was performed on 188 of 199.
- Hospitalization rate for the coronary CTA group was 19% versus 11% for the stress echocardiography group (difference 8%; 95% confidence interval 1-15%; p = 0.026).
- Median length of stay in discharged patients (time from randomization to discharge) in the coronary CTA group was 5.4 hours versus 4.7 hours in the stress echocardiography group (p < 0.001).
- Median length of stay in admitted patients (time from admission order to discharge) in the coronary CTA group was 58 hours versus 34 hours in the stress echocardiography group (p = 0.002).
- Safety outcomes showed no statistically significant differences in rates of major adverse cardiovascular events, all-cause death, nonfatal myocardial infarction, nonfatal stroke, nonfatal cardiac arrest, cardiac catheterization, revascularization from coronary artery bypass graft surgery or percutaneous coronary intervention, or serious complications from noninvasive imaging or revascularization over a median follow-up period of 733 days.
- New or increased pharmacotherapy for lipid-lowering medication in the coronary CTA arm was 14% versus 6% in the stress echocardiography arm (p = 0.01). In the coronary CTA group, beta-blocker medications were newly prescribed for 9% versus 4% in the stress echocardiography group (p = 0.04).
- Resource utilization showed no statistically significant differences in subsequent hospitalizations, emergency department visits, primary care visits, or cardiology outpatient visits over the complete follow-up period. Coronary CTA demonstrated alternate pathology in 10 patients: aortic intramural hematoma, ascending aortic aneurysm, stenotic bicuspid aortic valve, pulmonary emboli (3 patients), malignant pleural effusion, pneumonia, cholangiocarcinoma, and liver metastases. There were more admissions in the coronary CTA group for further assessment of diagnosed coronary artery disease, non-chest pain complaints, and pulmonary embolism.
- Radiation exposure was decreased in the stress echocardiography group through all evaluation periods.
- Subjective experience on multiple measures was more favorably rated by patients in the stress echocardiography group.
Conclusions:
Stress echocardiography was safe and effective in low- to intermediate-risk patients with chest pain in the emergency department who required noninvasive testing in this single-center trial. Compared with coronary CTA, stress echocardiography resulted in fewer hospital admissions, reduced length of stay for both admitted and discharged patients, no statistically significant difference in safety outcomes or resource utilization, lower radiation exposure, and better patient ratings. Stress echocardiography should be considered an appropriate option for evaluation of low- to intermediate-risk patients with chest pain in the emergency department.
Perspective:
Previous studies comparing early coronary CTA with standard evaluation, including myocardial perfusion imaging, patients with chest pain in the emergency department found that coronary CTA safely improved efficiency in clinical decision-making. This trial was a direct head-to-head comparison of coronary CTA with stress echocardiography (including dobutamine stress echocardiography if indicated) in low- to intermediate-risk patients with chest pain in a busy urban emergency department. Stress echocardiography resulted in improved clinical efficiency, reduced radiation exposure, better patient satisfaction, and no statistical differences in safety outcomes or resource utilization.
Clinical Topics: Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Interventions and Imaging, Angiography, Computed Tomography, Echocardiography/Ultrasound, Nuclear Imaging
Keywords: Echocardiography, Stress, Coronary Angiography, Tomography, Emission-Computed, Emergency Service, Hospital, Chest Pain, Diagnostic Tests, Routine, Decision Making, Intention to Treat Analysis, Length of Stay, Patient Satisfaction
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