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”