Using cardiac computed tomography angiography as part of a triage strategy in patients with possible acute coronary syndromes improved the efficiency of clinical decision making and shortened hospital stays in the ROMICAT II trial, but it increased radiation exposure and did not save any money, compared with standard ED evaluation.
That’s according to the final report of the Rule Out Myocardial Infarction/Ischemia Using Computer Assisted Tomography study, published July 25 in the New England Journal of Medicine [http://www.nejm.org/doi/full/10.1056/NEJMoa1201161]. We reported the preliminary results, presented by Dr. Udo Hoffmann of Massachusetts General Hospital in Boston at the annual meeting of the American College of Cardiology in Chicago in March 2012.
Dr. Rita F. Redberg
The experts we interviewed for the story noted that the cardiac computed tomography angiography (CCTA) testing did not improve diagnostic accuracy, but did expose the patients' radiation exposure, and probably overestimated the cost savings because the study included only those patients presenting during regular work hours.
Dr. Rita F. Redberg, professor of medicine and director of Women's Cardiovascular Services at the University of California, San Francisco, expanded on those themes in an editorial in response to both the ROMICAT II article and another, similar trial published in the journal in April.
“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.”
Dr. Redberg, who as editor of the Archives of Internal Medicine started its "Less Is More" feature a couple of years ago, acknowledging that the studies showed that a CCTA can be done in less time than a stress test. She added that "it is even faster to discharge these patients without any additional diagnostic test after determining that their ECG findings and troponin levels are normal. Thus, 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. Redberg is also on the editorial board of Cardiology News.