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Chest pain is a common complaint in the emergency department, and it is the job of clinicians to rule out life-threatening diagnoses such as acute coronary syndrome. The history, physical examination, cardiac risk factors, electrocardiogram findings, and clinician judgment are often not enough to distinguish between causes of chest pain syndromes and to reliably rule out acute myocardial ischemia. New cardiac troponin assays, especially in conjunction with clinical decision algorithms, help clinicians rapidly exclude acute myocardial infarction. For further risk stratification, stress testing or coronary computed tomography angiography can be used in the emergency department., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Study Objective: Three large, multicenter, randomized, clinical trials have shown that coronary computed tomography (CT) angiography allows efficient evaluation and safe discharge of patients with low- to intermediate-risk chest pain who present to the emergency department (ED). We report 1-year event rates and resource use from the American College of Radiology Imaging Network-Pennsylvania 4005 multicenter trial., Methods: Patients with low- to intermediate-risk chest pain and presenting to the ED were randomized in a 2:1 ratio to a coronary CT angiography care pathway or traditional care. Subjects were contacted by telephone at least 1 year after ED presentation. Medical record review was performed for all cardiac hospitalizations, procedures and diagnostic tests, and adverse cardiac events. Our main outcome was the composite of cardiac death and myocardial infarction within 1 year. The secondary outcome was resource use., Results: One thousand three hundred sixty-eight patients enrolled and 1,285 (94%) had direct participant or proxy contact at 1 year. All others had record review or death index search. From index presentation through 1 year, there was no difference between patients in the coronary CT angiography arm versus traditional care with respect to major adverse cardiac event (1.4% versus 1.1%; difference 0.3%; 95% CI -5.5% to 6.0%). From hospital discharge through 1 year, there was also no difference in ED revisits (36% versus 38%; difference -2.1%; 95% CI -7.9% to 3.7%), hospital admissions (16% versus 17%; difference -0.9%; 95% CI -6.7% to 4.9%), or subsequent cardiac testing (13% versus 13%; difference -0.4%; 95% CI -6.2% to 5.5%). One of 640 subjects with a negative coronary CT angiography result had a major adverse cardiac event within 1 year of presentation (0.16%; 95% CI 0.004% to 0.87%)., Conclusion: A coronary CT angiography-based strategy for evaluation of patients with low- to intermediate-risk chest pain who present to the ED does not result in increased resource use during 1 year. A negative coronary CT angiography result is associated with a less than 1% major adverse cardiac event rate during the first year after testing., (Copyright © 2015 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Background: Patients who present to the emergency department (ED) with symptoms of potential acute coronary syndrome (ACS) can be safely discharged home after a coronary computed tomographic angiography (CTA) with a negative result. However, the duration of time for which a negative coronary CTA scan result can be used to inform decision making when patients have recurrent symptoms is not known., Objective: We examined patients who received more than 1 coronary CTA for evaluation of ACS to determine whether they had disease progression. Our main outcome was whether any patient had a maximal stenosis cross the threshold from noncritical (<50% maximal stenosis) to potentially critical disease., Methods: We performed a structured comprehensive record search of all coronary CTAs performed from 2005 to 2010 at a tertiary care health system. Low-to-intermediate risk ED patients who received 2 or more coronary CTAs, at least 1 from an ED evaluation for potential ACS, were identified. Patients who were revascularized between scans were excluded. We collected demographic data, clinical course, time between scans, and number of ED visits between scans. Record review was structured and done by trained abstractors. Our main outcome was progression of coronary stenosis between scans, specifically crossing the threshold from noncritical to potentially critical disease., Results: Overall, 32 patients who received repeat imaging were identified (median age, 45 years; interquartile range, 37.5-48; 56% female; 88% black). The median time between studies was 27.3 months (interquartile range, 18.2-33.2). Twenty-two patients did not have stenosis in any vessel on either coronary CTA, 2 studies showed increasing stenosis of less than 20%, and the rest showed "improvement" due to better imaging quality. No patient initially below the 50% threshold subsequently exceeded it (0%; 95% confidence interval, 0-11.0%). No patient had acute myocardial infarction or revascularization either between scans or within a year after the repeated imaging., Conclusion: Repeated imaging potentially may not be warranted within 2 years of a negative coronary CTA result. The low rate of progression from subcritical to critical disease is consistent with observations in patients who have had prior negative cardiac catheterizations., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Reducing hospital admissions through improved risk stratification of patients with potential acute coronary syndrome represents a critical focus for reducing health care expenditure. Coronary computed tomographic angiography (CTA) has been used with increasing frequency as part of the evaluation of chest pain in the Emergency Department. In the appropriate group of patients at low to intermediate risk CTA appears to be an excellent evaluation strategy, safely and efficiently allowing for the rapid discharge of patients home., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to determine if patients presenting with symptoms of acute coronary syndrome and found to have 25% to 50% diameter reduction with coronary computed tomographic angiography (CCTA) are likely to benefit from further diagnostic testing., Methods: A registry study of 213 subjects (median age, 51 years; 53% women) with symptoms concerning for possible acute coronary syndrome with low-risk features found to have 25% to 50% maximal diameter stenosis on CCTA was performed at 2 academic medical centers. The analysis was approved by an institutional review board and was conducted with waiver of consent. The potential contribution of additional testing was determined by measuring the major adverse cardiac events (MACEs) from presentation through 30 days. The MACEs included myocardial infarction, coronary revascularization, unstable angina, and cardiovascular death. Sample size calculations were predicated on a 0% MACE rate leading to upper bounds of a 2-sided exact 95% confidence interval less than 2%., Results: Thrombolysis in myocardial infarction risk score of less than 2 was present in 92% subjects, 70% (150 of 213) had 2 or more serial cardiac markers performed, and 40% (87 of 213) had stress testing or cardiac catheterization. The MACEs occurred in 1 (0.5%) of 213 subjects (95% confidence interval, 0%-2.6%) and was identified by an elevation of serial cardiac markers during the index hospitalization. No patients experienced cardiovascular death or required revascularization., Conclusions: In patients with emergent low-risk chest pain and 25% to 50% diameter coronary stenosis by CCTA, the rate of near-term MACE is very low. Serial cardiac markers may be beneficial in this subgroup. Routine provocative testing is unlikely to be beneficial during the index visit., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Objectives:   The authors assessed whether there was a sex disparity in testing of patients after coronary computerized tomographic angiography (CTA) was performed for emergency department (ED) patients with potential acute coronary syndromes (ACS). In theory, once coronary anatomy has been determined, any disparity in subsequent workup should not be the result of differences in presentation., Methods:   This was a prospective cohort study of ED patients who presented with potential ACS and received coronary CTAs at a university hospital. Demographics, history, cardiac risk factors, follow-up testing, and procedures were recorded. Follow-up at 30 days was obtained by structured record review and telephone contact. Patients were stratified by sex and coronary CTA results (max stenosis: none, 1% to 24%, 25% to 49%, 50% to 69%, and ≥70%). Main outcome was the relative risk (RR) of a male receiving a stress test or catheterization within 30 days, stratified by categories of percent maximal stenosis., Results:   A total of 1,144 patients received coronary CTAs (mean ± SD age = 47.8 ± 8.7 years), 55% were female, and 64% were black or African American. Overall, 161 patients received follow-up testing within 30 days, 113 during their index visit. Men were more likely to receive further testing (RR = 1.51; 95% confidence interval [CI] = 1.14 to 1.99) compared to women. However, when stratified by percentage of stenosis, men were not more likely to receive further testing within 30 days after coronary CTA compared to women (RR = 1.14; 95% CI = 0.68 to 1.91). In multivariable modeling for risk of further testing, stenosis remained significant (adjusted relative risk [aRR] = 1.51; 95% CI = 1.19 to 1.91), while male sex, age, race, and Thrombolysis in Myocardial Infarction (TIMI) risk score were not., Conclusions:   Male patients with potential ACS who receive a coronary CTA as a part of their ED evaluation were no more likely than female patients to receive further testing within 30 days., (© 2012 by the Society for Academic Emergency Medicine.)

Objectives: Coronary angiography calcium score (CACS) is included for patients who receive coronary computed tomography angiography (CTA) as part of diagnostic testing for low-risk chest pain. Both tests add radiation exposure, and it is unclear whether the combination provides more information than either test alone. The objective was to asses if CACS = 0 determines freedom from coronary artery disease (CAD) and whether the addition of CACS to coronary CT angiography provides additional risk stratification information or helps predict 30-day cardiovascular outcomes., Methods: This was a secondary analysis of a prospective cohort study at an urban university hospital emergency department (ED), of patients with symptoms suggestive of potential acute coronary syndrome (ACS) and low Thrombolysis in Myocardial Infarction (TIMI) risk scores who received coronary CTA. Data collected included demographics and medical history. The main outcome was CAD, defined as the presence of a maximal stenosis >50% on coronary CTA, stratified by CACS results. The secondary outcome was cardiovascular events including death, myocardial infarction, or revascularization at 30 days. Data were analyzed with standard descriptive techniques and relative risks (RR) with 95% confidence intervals (CIs)., Results: A total of 1,049 patients were enrolled (median age = 48.1 years; interquartile range [IQR] = 42.4 to 53.3 years); 55% were female, and 63% were black or African American. Of these, 17 of 795 (2.1%) with CACS of 0 had CAD, 16 of 169 patients (9.5%) with CACS of 0.1 to 99 had CAD, 53.3% (32 of 60) with CACS between 100 and 399 had CAD, and 10 of 23 (43.5%) with CACS ≥ 400 had CAD. There was a higher likelihood of significant CAD with increased CACS. Patients who had a calcium score of 0 but still had CAD were more likely to be young (50 years old or less; RR = 1.73, 95% CI = 1.01 to 2.96). For the secondary outcome, there were 15 cardiovascular events within 30 days: one patient with CACS = 0 and no CAD (1 of 733; 0.1%), one patient with CACS > 0 and no CAD (1 of 182; 0.5%), four patients with CACS = 0 and CAD (4 of 17; 23.5%), and nine patients with CACS > 0 and CAD (9 of 58; 15.5%), with a net reclassification index of -0.001 (p = 0.32)., Conclusions: In the study sample, elevated CACS was associated with a higher likelihood of underlying CAD on coronary CTA, but the addition of CACS to coronary CTA did not help predict 30-day cardiovascular events., (© 2011 by the Society for Academic Emergency Medicine.)

Background: Most patients presenting to emergency departments (EDs) with cocaine-associated chest pain are admitted for at least 12 hours and receive a "rule out acute coronary syndrome" protocol, often with noninvasive testing prior to discharge. In patients without cocaine use, coronary computerized tomography angiography (CTA) has been shown to be useful for identifying a group of patients at low risk for cardiac events who can be safely discharged. It is unclear whether a coronary CTA strategy would be efficacious in cocaine-associated chest pain, as coronary vasospasm may account for some of the ischemia. We studied whether a negative coronary CTA in patients with cocaine-associated chest pain could identify a subset safe for discharge., Methods: We prospectively evaluated the safety of coronary CTA for low-risk patients who presented to the ED with cocaineassociated chest pain (self-reported or positive urine test). Consecutive patients received either immediate coronary CTA in the ED (without serial markers) or underwent coronary CTA after a brief observation period with serial cardiac marker measurements. Patients with negative coronary CTA (maximal stenosis less than 50%) were discharged. The main outcome was 30-day cardiovascular death or myocardial infarction., Results: A total of 59 patients with cocaine-associated chest pain were evaluated. Patients had a mean age of 45.6 +/- 6.6 yrs and were 86% black, 66% male. Seventy-nine percent had a normal or nonspecific ECG and 85% had a TIMI score <2. Twenty patients received coronary CTA immediately in the ED, 18 of whom were discharged following CTA (90%). Thirty-nine received coronary CTA after a brief observation period, with 37 discharged home following CTA (95%). Six patients had coronary stenosis >or=50%. During the 30-day follow-up period, no patients died of a cardiovascular event (0%; 95% CI, 0-6.1%) and no patient sustained a nonfatal myocardial infarction (0%; 95% CI, 0-6.1%)., Conclusions: Although cocaine-associated myocardial ischemia can result from coronary vasoconstriction, patients with cocaine associated chest pain, a non-ischemic ECG, and a TIMI risk score <2 may be safely discharged from the ED after a negative coronary CTA with a low risk of 30-day adverse events.

Objectives: Coronary computerized tomographic angiography (CTA) has high correlation with cardiac catheterization and has been shown to be safe and cost-effective when used for rapid evaluation of low-risk chest pain patients from the emergency department (ED). The long-term outcome of patients discharged from the ED with negative coronary CTA has not been well studied., Methods: The authors prospectively evaluated consecutive low- to intermediate-risk patients who received coronary CTA in the ED for evaluation of a potential acute coronary syndrome (ACS). Patients with cocaine use, known cancer, and significant comorbidity reducing life expectancy and those found to have significant disease (stenosis > or = 50% or ejection fraction < 30%) were excluded. Demographics, medical and cardiac history, labs, and electrocardiogram (ECG) results were collected. Patients were followed by telephone contact and record review for 1 year. The main outcome was 1-year cardiovascular death or nonfatal acute myocardial infarction (AMI)., Results: Of 588 patients who received coronary CTA in the ED, 481 met study criteria. They had a mean (+/-SD) age of 46.1 (+/-8.8) years, 63% were black or African American, and 60% were female. There were 53 patients (11%) rehospitalized and 51 patients (11%) who received further diagnostic testing (stress or catheterization) over the subsequent year. There was one death (0.2%; 95% confidence interval [CI] = 0.01% to 1.15%) with unclear etiology, no AMI (0%; 95% CI = 0 to 0.76%), and no revascularization procedures (0%; 95% CI = 0 to 0.76%) during this time period., Conclusions: Low- to intermediate-risk patients with a Thrombosis In Myocardial Infarction (TIMI) score of 0 to 2 who present to the ED with potential ACS and have a negative coronary CTA have a very low likelihood of cardiovascular events over the ensuing year.

Study Objective: Coronary computed tomographic (CT) angiography has excellent performance characteristics relative to coronary angiography and exercise or pharmacologic stress testing. We hypothesize that coronary CT angiography can identify a cohort of emergency department (ED) patients with a potential acute coronary syndrome who can be safely discharged with a less than 1% risk of 30-day cardiovascular death or nonfatal myocardial infarction., Methods: We conducted a prospective cohort study at an urban university hospital ED that enrolled consecutive patients with potential acute coronary syndromes and a low TIMI risk score who presented to the ED with symptoms suggestive of a potential acute coronary syndrome and received a coronary CT angiography. Our intervention was either immediate coronary CT angiography in the ED or after a 9- to 12-hour observation period that included cardiac marker determinations, depending on time of day. The main clinical outcome was 30-day cardiovascular death or nonfatal myocardial infarction., Results: Five hundred sixty-eight patients with potential acute coronary syndrome were evaluated: 285 of these received coronary CT angiography immediately in the ED and 283 received coronary CT angiography after a brief observation period. Four hundred seventy-six (84%) were discharged home after coronary CT angiography. During the 30-day follow-up period, no patients died of a cardiovascular event (0%; 95% confidence interval [CI] 0% to 0.8%) or sustained a nonfatal myocardial infarction (0%; 95% CI 0 to 0.8%)., Conclusion: ED patients with symptoms concerning for a potential acute coronary syndrome with a low TIMI risk score and a nonischemic initial ECG result can be safely discharged home after a negative coronary CT angiography test result.

Objectives: Small studies have shown that a negative computed tomography coronary angiogram (CTA) in low-risk chest pain patients predicts a low rate of 30-day adverse events. The authors hypothesized that an immediate CTA strategy would be as effective but less costly than alternative strategies for evaluation of patients with potential acute coronary syndrome (ACS)., Methods: The authors retrospectively compared four strategies for evaluation of patients after initial physician determination that the patient required admission and testing to rule out ACS. Patients were frequency-matched by age, race, gender, thrombolysis in myocardial infarction (TIMI) score, and initial electrocardiogram (ECG). The four groups were immediate CTA in the emergency department (ED) without serial markers (n = 98); clinical decision unit/observation unit (CDU) with biomarkers and CTA (n = 102); CDU evaluation with serial cardiac biomarkers and stress testing (n = 154); and usual care, defined as admission with serial biomarkers and hospitalist-directed evaluation (n = 289). The main outcomes were actual cost of care (facility direct and indirect fixed, facility variable direct labor and supply costs), length of stay (LOS), diagnosis of coronary artery disease (CAD), and safety (30-day death or myocardial infarction [MII)., Results: Patients in each group were of similar age (mean +/- standard deviation [SD] 46 +/- 9 years), race (62% African American), and gender (57% female) and had similar TIMI scores (100% between 0-2). Comparing immediate CTA versus CDU CTA versus CDU stress versus usual care, median costs were less ($1,240 vs. 2,318 vs. 4,024 vs. 2,913; p < 0.01), and LOS was shorter (8.1 hr vs. 20.9 hr vs. 26.2 hr vs. 30.2 hr; p < 0.01). Diagnosis of CAD was similar (5.1% vs. 5.9% vs. 5.8% vs. 6.6%; p = 0.95), but fewer patients had 30-day death/MI (0% vs. 0% vs. 0.7% vs. 3.1%; p = 0.04) or 30-day readmission (0% vs. 3.2% vs. 2.3% vs. 12.2%; p < 0.01)., Conclusions: Compared to the other strategies, immediate CTA was as safe, identified as many patients with CAD, had the lowest cost, had the shortest LOS, and allowed discharge for the majority of patients. Larger prospective studies should confirm safety before immediate CTA replaces other strategies to rule out possible ACS.