CCTA Helps Clear Emergency Departments, But Costs Remain High

"With no evidence of benefit and definite risks, routine testing in the emergency department of patients with a low-to-intermediate risk of acute coronary syndromes should be avoided," Dr. Rita F. Redberg argued in an accompanying editorial (N. Engl. J. Med. 2012;367:375-6) on the findings.

"In short, the question is not which test leads to faster discharge of patients from the emergency department, but whether a test is needed at all."

ROMICAT-II builds on similar data from another study that also randomly assigned patients with suspected acute coronary syndromes to CCTA or traditional care (N. Engl. J. Med. 2012;366:1393-403).

While shorter lengths of stay in the hospital are highly desirable, "the ROMICAT-II study reveals a deeper flaw in the approach to chest pain in the emergency department. The underlying assumption of these two studies is that some diagnostic test must be performed before discharging these low-to-intermediate-risk patients from the emergency department. This assumption is unproven and probably unwarranted. The rationale for any test, as compared with no testing, should be that it will lead to an improved outcome, and here there is no evidence that the tests performed led to improved outcomes," said Dr. Redberg.

She explained that rates of major adverse cardiac events among all patients in these two studies – regardless of whether the patients underwent CCTA, stress testing, or no testing at all – were so low (less than 1% had a myocardial infarction and no patients died) that it is impossible to know whether the CCTA groups received any benefit whatsoever.

Dr. Redberg pointed out several potential dangers associated with CCTA, such as the increased likelihood of downstream testing after CCTA that can lead to serious complications.

"In light of the certainty that the patients in the CCTA group were exposed to substantial doses of radiation (from both CCTA and nuclear stress tests) and were at risk for nephrotoxicity and adverse reactions from the CCTA contrast dye, clinicians may legitimately ask whether the tests did more harm than good," she observed.

"Patients who have normal electrocardiographic findings and negative troponin levels constitute a group at low risk for cardiac events, and multiple studies show no evidence that any additional testing further reduces that risk," she said.

The decision regarding the need for diagnostic testing in these patients usually can be safely deferred to outpatient follow-up within a few weeks after the visit to the emergency department. The vast majority of patients have no cardiac causes for their chest pain, and many need no further testing.

Dr. Redberg is a professor of medicine and the director of Women’s Cardiovascular Services at the University of California, San Francisco. Dr. Redberg is also on the editorial board of Cardiology News. She reported that she has no conflicts of interest.