Monday, January 25, 2016

CTCA in the ED, Getting Less Sexy By The Day

As I’ve written before, the CT coronary angiograms is a funny test.  The idea of having a non-invasive method of detecting previously unknown coronary artery disease is compelling.  The practical application, however, has been limited by a low specificity – further exacerbated by those encouraging its use in a population with low pretest probability.

However, the few major studies regarding it tend to view CTCA in a favorable light – the result of comparing CTCA-based strategies to modern over-triage and over-testing of potential acute coronary syndrome.  These studies, ACRIN-PA and ROMICAT, showed significant improvements in direct discharge from the ED and in length-of-stay, not so much due to being a superior strategy of benefit to patients, but by obviating unnecessary care inflicted upon them.

The general gist of this trial is framed in the “era of high-sensitivity troponins” – referring to new developments in assays allowing a safer rapid rule-out in the Emergency Department.  This trial, as opposed to the others, also occurs in the Netherlands, a setting in which direct discharge from the ED is no anathema.  The “standard care” arms of ACRIN-PA and ROMICAT-2 had discharge rates from the ED of ~20% or less, while this trial discharges nearly 60%.  Yet, despite such recklessness displayed in this trial, these patients are ultimately just as safe.  And, when such an insanity-reduction initiative is undertaken, the advantages of CTCA diminish.

And, frankly, nearly all low-risk patients can be discharged safely from the Emergency Department.  The appropriate urgent follow-up test, if any, is a trickier proposition – and CCTA may yet be appropriate for some.  However, as a routine, ED-based strategy, it should probably be considered low-value care.

“Coronary CT Angiography for Suspected ACS in the Era of High-Sensitivity Troponins”
http://content.onlinejacc.org/article.aspx?articleID=2479881

2 comments:

  1. Hello, there,
    Thanks for fishing this.

    I can't comment on the paper but what I read in the abstract is intersting.

    A somewhat physician influenced outcome (patients identified with significant coronary artery disease requiring revascularisation within 30 days. The the best fullproof endpoint , ikely the "least worse" for the patient number in the study.

    A test, CTCA, that does not improve this outcome.
    But that seems to stop dotors from further investigating patients:
    "The CCTA group ... less outpatient testing after the index ED visit (10 [4%] vs. 26 [10%], p < 0.01).".

    I'm still to understand how one can explain that adding CTCA , within a 6hours stay in the ED may lead to this finding:

    "The CCTA group had lower direct medical costs (€337 vs. €511, p < 0.01)".


    Oh and by the way, what do our West of the pond colleagues think of the efficiency of a system , in the Netherlands where the cost of 6 hours in the ED with troponins, nurses, docs, documentation, and a high tech imaging study results in MEDICAL COSTS OF €337 vs. €511 without the CTCA. (I hope I didnt miss something).

    This last paragraph is in tongue in cheek - leg-pulling mode of course.

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    Replies
    1. The costs are a bit of a funny outcome – and they're the least generalizable bit of the paper, so that's why I tend to refrain from commenting on those. I, too, am a little befuddled regarding an outcome based on follow-up studies ... that most ignores the fact that _every_ patient in the CCTA arm received a follow-up study (the CCTA).

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