We all realize what a challenge the ED has in the diagnosis of chest pain patients. Six million chest pain patients present to ED's in U.S. hospitals each year. Of these, 75% are found to have non-ischemic or non-cardiac etiologies for their chest pain. The diagnostic cost of diagnosing these patients is estimated at $12 to $14 billion a year. About 2% to 4% of acute coronary syndromes are missed and inappropriately discharged. This leads to an estimated 20% of malpractice costs being assigned to missed diagnosis of chest pain in the ED each year. The standard-of-care testing (rest and stress imaging after serial electrocardiograph and cardiac enzyme tests) for chest pain patients is time consuming and resource intensive, with results that are not always definitive.
In the study 750 low-risk chest pain patients were randomized in 16 hospital sites to receive either CT angiography or standard-of-care workups in an attempt to produce a diagnosis. The results of the trial were striking:
- The use of CT resulted in a mean diagnosis time of 2.9 hours, compared to 6.2 hours for the standard of care.
- Use of CT decreased the overall radiation exposure from about 15 mSv for the standard of care to 10.8 mSv for CT angiography.
- Use of CT decreased overall costs for patients from a mean of $3,458 for standard of care to $2,137 for CT angiography.
In summary, the trial concludes that the use of CT angiography was safe, faster, and cheaper than the standard of care. CFA encourages all hospitals with emergency departments and cardiac CT technology to evaluate chest pain strategies based on cardiac CT angiography, but cautions that there are many factors that must be considered with implementation. Including:
- Availability of CT (specifically technical staff and interpreting physicians) within the hospital, particularly beyond daytime hours.
- Interpretation by qualified physicians. After hours coverage is particularly problematic and may require the use of a night read services, which increases costs.
- Development of protocols that highlight the indications and contraindications for the test, importance of heart rate control, administration of beta blockers and the like to obtain appropriate and assessable studies. Not every patient is a candidate for coronary CT.
- Continuing quality audits that track the quality of the studies and pinpoint non-assessable studies, and continuous review of CT cases as part of appropriate monthly multi-disciplinary conferences.
- Often problematic reimbursement.
For further information on CT-STAT, CFA refers you to http://directnews.americanheart.org/extras/sessions2009/slides/159_sslides.pdf