2. Background
 Chest Pain due to ACS is one of the
most common presentations to ER
 Current strategies to R/O ACS are
inefficient – Unnecessary admissions
and ER overcrowded
 Despite low threshold to admit patients
up to 2% of patients Discharged with
missed ACS

3. Cardiac CT Angiography
 Previous studies Showed that CCTA has
Accurate Noninvasive Detection of
significant CAD with High NPV during
the index hospitalization and the
occurrence of major adverse
cardiovascular events over the next 2
years
Hollander JE, Chang AM, Shofer FS, et al. One-year outcomes following coronary computerized tomographic angiography for evaluation of
emergency department patients with potential acute coronary syndrome. Acad Emerg Med 2009;16:693-8
Schlett CL,, et al.
Prognostic value of CT angiography for major adverse cardiac events in patients with acute chest pain from the emergency department: 2-year
outcomes of the ROMICAT trial. JACC Cardiovasc Imaging 2011;4:481-91

4. The hypothesis
 An evaluation strategy incorporating
early CCTA will improve the
effectiveness of clinical decision making
as compared to a Standard ED
Evaluation in Patients with acute chest
pain suggestive of ACS
 Study Type : Diagnostic cohort
 Study Design : RCT

5. P  40 to 74 years of age with symptoms
suggestive of ACS but without ischemic
ECG Changes or an initial positive
troponin test
I  CCTA
C  Standard Evaluation
O  Primary End Point, length of stay in the
hospital

6. Secondary Endpoints
 Rates of direct discharge from the ED
 Cumulative costs
 Cumulative radiation exposure
 Time to diagnosis
 Safety variables (Periprocedural
complications, undetected acute coronary
syndrome within 72 hrs after discharge,
MACE at 28 days)
 Utilization of other diagnostic testing
 Resource utilization

7. Inclusion Criteria
 Patients with > 5 min of Chest Pain or
Angina Equivelant within the past 24
hours
 40 to 74 years of age
 sinus rhythm Patients
 Patient must be able to Hold Breath >10
seconds
 Patient must be able to sign an informed
consent

8. Exclusion Criteria
 History of known coronary artery disease !!
 New diagnostic ischemic changes on the
initial ECG
 Initial troponin level in excess of the 99th
percentile of the local assay
 Impaired renal function
 Hemodynamic or clinical instability,
 Known allergy to an iodinated contrast
agent
 Body Mass Index greater than 40
 Currently symptomatic asthma.

10. Was the assignment of
patients to treatments
randomized?
 Yes, randomly assigned in a 1:1 ratio

11. Was the randomization
Concealed ?
 No

12. Were the groups similar at
the start of the trial?
 Yes

15. Aside from the allocated
treatment were groups treated
equally?
 Yes, and both arms were Followed up for 28
Days

16. Were all patients who entered
the trial accounted for?
 No, Almost 1% lost the Follow up

18. Were Patients analysed in the
groups to which they were
randomized?
 Yes, with the use of intention to treat analysis

19. Were measures objective
?
 Yes, they were objectives (Length of
stay and cost and Radiation Exposure)

20. Were the patients and
clinicians kept “blind” to
which treatment was being
received?
 No, it wasn’t Blind

21. Results

25. Summary
 CCTA has:
 High Diagnostic Accuracy
 Less Time to Dx
 More Direct Discharge From ER
 Reduce Length of stay
 More cost !!
 More Radiation

26. Will the results help me in
caring for my patient?
 Yes, But to a limited group of patients

27. Applicability of the study
 Patients were recruited at weekday
daytime hours
 Patients with History of
 Known coronary artery disease
 Hemodynamic or clinical instability
 Impaired renal function
 Limited age group
were excluded
 We can Apply CCTA in our institution