Cardiac CT in the Emergency Department: Contrasting Evidence from Registries and Randomized Controlled Trials

Impact of Education-based HEART Score Pathway on Coronary Computed Tomography Angiography Utilization and Yield in the Emergency Department

OBJECTIVE

There is a growing consensus to reduce unnecessary testing among low-risk chest pain patients. The objective of this study was to evaluate the impact of implementing an education-based HEART score pathway in the emergency department on coronary computed tomography angiography (CCTA) utilization and yield.

METHODS

A retrospective before and after intervention study was conducted at a single site. Adult emergency department patients undergoing CCTA for suspected acute coronary syndrome were included. Primary outcomes were CCTA utilization and yield. Utilization was defined as the percentage of patients evaluated with CCTA and yield was calculated as the percentage of patients with a diagnosis of obstructive coronary artery disease, defined as ≥50% stenosis in any one coronary artery due to atherosclerosis.

RESULTS

1540 patients undergoing CCTAs were included. CCTA utilization before and after were 2.2% [95% confidence interval (CI) 2.0-2.3] and 2.0% (95% CI 1.9-2.2), respectively; mean difference 0.1% (95% CI -0.1 to 0.3; P = 0.21). The mean age was 53 years (SD = 11) and females were 52%. Of 1477 patients included in CCTA yield analysis, patients diagnosed with obstructive coronary artery disease before and after were 15.0% (95% CI 12.6-17.7) and 16.2% (95% CI 13.6-19.1), respectively; mean difference 1.2% (95% CI -2.6 to 5.1; P = 0.53).

CONCLUSIONS

There was no significant change in the CCTA utilization or yield after the implementation of an education-based HEART pathway in a large academic center. Our findings suggest adopting a more comprehensive approach for deploying such evidence-based protocols to increase institutional compliance.

Acute Coronary and Acute Aortic Syndromes

Multidetector-row computed tomography (MDCT) can provide crucial information and rapid triage of emergency department patients with suspected acute coronary syndrome (ACS) or acute aortic syndrome (AAS). Coronary computed tomography angiography has high negative predictive value to rule out ACS, and MDCT is diagnostic for AAS and its variants. Optimization of acquisition technique and up-to-date knowledge of the pathophysiology of these conditions can improve study and interpretation quality for diagnosis of ACS or AAS.