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Patients with suspected acute coronary syndrome (ACS) are often admitted to the hospital after presentation at the emergency department (ED), but in most cases, their symptoms are eventually found to have non-cardiac causes. Various testing protocols to identify low-risk patients have attempted to decrease unnecessary hospital admissions. Multidetector computed tomography angiography (MDCTA) can be used to rule out significant coronary artery disease and may be able to rule out ACS in patients presenting with chest pain. A recent randomized trial of 1,392 low-risk patients with suspected ACS (mean age 49 years) evaluated whether use of MDCTA could safely increase the rate of patients discharged without hospital admission.
Patients with a Thrombolysis in Myocardial Infarction (TIMI) risk score 0-2 (0-7 scale), who had been determined by the treating physician to require either admission or objective testing to rule out ACS were randomized to MDCTA vs. standard care. Of 929 patients randomized to MDCTA, 767 had the scan, and 83% of those had a negative result defined as coronary artery stenosis < 50%.
The rate of discharge from ED to home was 49.6% for MDCTA vs. 22.7% for standard care (p < 0.05, NNT 4), and MDCTA was associated with significantly shorter median hospital stay (18 hours vs. 24.8 hours, p < 0.001). At 30-day follow-up, no patients in either group had died, and there were no significant differences in rates of acute myocardial infarction, revascularization or invasive angiography (level 2 [mid-level] evidence) (N Engl J Med 2012 Apr 12;366(15):1393). It should emphasized that the lower rates of hospitalization demonstrated here were based on comparison to “usual care” and not to other methods for rapid evaluation, such as stress testing, in the Emergency Department.
For more information, see the Acute coronary syndrome topic in DynaMed.