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Coronary computed tomographic angiography for detection of coronary artery disease in patients presenting to the emergency department with chest pain: a meta-analysis of randomized clinical trials

  
  
  
  
  
European Journal of Echocardiography, 12/10/2012

D'Ascenzo F et al. – The authors performed a meta–analysis to test the safety and efficacy of this non–invasive diagnostic approach in low– and intermediate–risk chest pain patients. The present meta–analysis shows that a strategy with coronary computed tomographic angiography (CCTA) used as first imaging test for low– and intermediate–risk patients presenting to the ED with chest pain appears safe and seems not to increase subsequent invasive coronary angiographies. The approach is cost–effective although limited data and incomplete cost analyses have been performed. CCTA increases coronary revascularizations, with still an unknown effect on prognosis, especially in the long term.

Methods

  • MEDLINE/PubMed was systematically screened for RCTs comparing CCTA and non–CCTA approaches for ED patients presenting with chest pain.
  • Baseline features, diagnostic strategies, and outcome data were appraised and pooled with random–effect methods computing summary estimates [95% confidence intervals (CIs)].
  • A total of four RCT studies including 2567 patients were identified, with similar inclusion and exclusion criteria.

Results

  • Patients in the CCTA group were more likely to undergo percutaneous or surgical revascularization during their index visit, with an odd ratio of 1.88 (1.21–2.92).
  • Time to diagnosis was reduced with CCTA (–7.68 h;–12.70 to 2.66) along with costs of care in the ED (–$680; –1.060 to –270: all CI 95%).



Fabrizio D'Ascenzo (12/10/2012) comments:

Patients with low risk chest pain (negative troponin and ECG) are very difficult to manage, with 10% about of risk to miss diagnosis of Coronary Artery Disease.
In the present meta-analysis we demonstrated that coronary CT is first safe (no increase adverse events in the follow up), and cost-effective when compared to normal care (like scintigraphy).
The next big question derives from another finding that is increases rates of revascularization in CT; it these data derive only from "oculostenotic" view, or from high accuracy is still a matter a debate, as the impact on prognosis.

Fabrizio D'Ascenzo

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