Examining Efficiency of Coronary CT Exam vs. Stress Test (GXT) in Patients with Acute Chest Pain Admitted to the Emergency Department

Only 10% of patients with chest pain are diagnosed with acute coronary syndrome (ACS) generating large work burden on emergency units. Recent studies demonstrated the effectiveness of coronary CT to rule out ACS. However, CTA may generate unnecessary procedures leading to greater costs than standard evaluation. Thus, the cost effectiveness of this imaging modality is questionable. We conducted a randomized prospective analysis of the cost effectiveness CTA in patients with acute chest pain compared to standard care strategy in an Israeli tertiary center.

Methods: Patients aged 30-65 years, with chest pain who were admitted for observation with neither ECG changes nor elevated troponin were randomized to either CTA or GXT. Patients with known coronary disease are excluded. Patients were followed up for six months. The primary endpoint was the number and cost of downstream diagnostic tests at six months after discharge. Secondary endpoint was length of stay in the hospital.

Results: 103 patients were randomized, 51 to the CTA arm and 52 to GXT. There were no demographic differences between the arms. In the CTA arm, 8 catheterizations were performed 6 of which underwent PCI. In the GXT 6 catheterizations were performed, with only one PCI. At six month the number of subsequent ambulatory tests were 15 (29%) in the CT arm and 25 (48%) in the GXT arm (p=0.048). This difference was mainly driven by more CTA and GXT in the GXT arm. Mean duration of hospitalization (days) was 1.3 ± 1.9 in the CTA arm and 1.6 ± 2.0 in the GXT arm (p=0.729).

Conclusion: Evaluation of acute chest pain with coronary CTA does not prolong hospitalization duration, causes less downstream testing at six months, and is not more expensive than GXT.