CT Coronary Angiography IDs Low-Risk Chest Pain Patients

SAN FRANCISCO — Chest pain patients who have a negative CT coronary angiogram can be safely discharged home with an extremely low risk of poor cardiac outcomes at 30 days, Dr. Anne Marie Chang said at the 12th International Conference on Emergency Medicine.

“Prior algorithms have been unable to identify a cohort of patients who have less than a 1% risk of adverse events after discharge,” said Dr. Chang, an emergency medicine resident at the Hospital of the University of Pennsylvania, Philadelphia. “While observation units do allow us to identify this low-risk cohort, they require serial cardiac markers, stress testing, and electrocardiograms, which increase the length of stay in the emergency department.”

Dr. Chang and her colleagues examined 30-day outcomes in a cohort of 568 patients who received CT coronary angiography (CTA) after admission to the ED for chest pain. Half of the patients (285) received their CTA in the ED, with no cardiac markers required; the rest received the procedure after a stay in the observation unit and two or three sets of negative cardiac markers.

All patients had a score of 0–2 on the Thrombolysis in Myocardial Infarction (TIMI) scale. Most patients were black and female; their mean age was 47 years. Hypertension was present in 44% of patients. In two-thirds of patients, the initial electrocardiogram was normal or nonspecific.

Of the 568 patients, 525 had a negative CTA (no lesion of 70% or greater, and a coronary calcium score of less than 100).

In the group of patients who received CTA while in the ED, 81% were discharged home and 19% were admitted, primarily because of confounding medical problems. Stress tests were performed on 13 patients; 2 had positive results and underwent cardiac catheterization. For both of those patients, the catheterization results matched the CTA results; both were medically managed.

In the group that received CTA after an observation unit stay, 97% were discharged home and 3% were admitted. Five patients underwent a stress test, with one positive result. “This patient had a 60% lesion, which was seen on CTA and catheterization, and he received a cardiac stent,” Dr. Chang said at the meeting, which was hosted by the American College of Emergency Physicians.

Most of the cohort with negative CTA results (90%) were contacted by telephone 30 days after discharge. Follow-up on the remainder was performed by a record review and a review of the National Death Index.

The only death resulted from a motor vehicle accident. There were no cardiac deaths, no acute myocardial infarctions, and no revascularizations within the follow-up period.

In addition to accurately identifying those chest pain patients who can be safely discharged from the ED, CTA can also be used as a post-observation-unit discharge strategy, Dr. Chang said.

Studies also show that, compared with stress testing, patients who receive angiography have fewer repeat ED visits and hospitalizations, higher satisfaction with their care, and a better understanding of their disease, Dr. Chang noted.

Patients who receive angiography have fewer repeat ED visits and hospitalizations. DR. CHANG

SAN FRANCISCO — Chest pain patients who have a negative CT coronary angiogram can be safely discharged home with an extremely low risk of poor cardiac outcomes at 30 days, Dr. Anne Marie Chang said at the 12th International Conference on Emergency Medicine.

“Prior algorithms have been unable to identify a cohort of patients who have less than a 1% risk of adverse events after discharge,” said Dr. Chang, an emergency medicine resident at the Hospital of the University of Pennsylvania, Philadelphia. “While observation units do allow us to identify this low-risk cohort, they require serial cardiac markers, stress testing, and electrocardiograms, which increase the length of stay in the emergency department.”

Dr. Chang and her colleagues examined 30-day outcomes in a cohort of 568 patients who received CT coronary angiography (CTA) after admission to the ED for chest pain. Half of the patients (285) received their CTA in the ED, with no cardiac markers required; the rest received the procedure after a stay in the observation unit and two or three sets of negative cardiac markers.

All patients had a score of 0–2 on the Thrombolysis in Myocardial Infarction (TIMI) scale. Most patients were black and female; their mean age was 47 years. Hypertension was present in 44% of patients. In two-thirds of patients, the initial electrocardiogram was normal or nonspecific.

Of the 568 patients, 525 had a negative CTA (no lesion of 70% or greater, and a coronary calcium score of less than 100).

In the group of patients who received CTA while in the ED, 81% were discharged home and 19% were admitted, primarily because of confounding medical problems. Stress tests were performed on 13 patients; 2 had positive results and underwent cardiac catheterization. For both of those patients, the catheterization results matched the CTA results; both were medically managed.

In the group that received CTA after an observation unit stay, 97% were discharged home and 3% were admitted. Five patients underwent a stress test, with one positive result. “This patient had a 60% lesion, which was seen on CTA and catheterization, and he received a cardiac stent,” Dr. Chang said at the meeting, which was hosted by the American College of Emergency Physicians.

Most of the cohort with negative CTA results (90%) were contacted by telephone 30 days after discharge. Follow-up on the remainder was performed by a record review and a review of the National Death Index.

The only death resulted from a motor vehicle accident. There were no cardiac deaths, no acute myocardial infarctions, and no revascularizations within the follow-up period.

In addition to accurately identifying those chest pain patients who can be safely discharged from the ED, CTA can also be used as a post-observation-unit discharge strategy, Dr. Chang said.

Studies also show that, compared with stress testing, patients who receive angiography have fewer repeat ED visits and hospitalizations, higher satisfaction with their care, and a better understanding of their disease, Dr. Chang noted.

Patients who receive angiography have fewer repeat ED visits and hospitalizations. DR. CHANG

SAN FRANCISCO — Chest pain patients who have a negative CT coronary angiogram can be safely discharged home with an extremely low risk of poor cardiac outcomes at 30 days, Dr. Anne Marie Chang said at the 12th International Conference on Emergency Medicine.

“Prior algorithms have been unable to identify a cohort of patients who have less than a 1% risk of adverse events after discharge,” said Dr. Chang, an emergency medicine resident at the Hospital of the University of Pennsylvania, Philadelphia. “While observation units do allow us to identify this low-risk cohort, they require serial cardiac markers, stress testing, and electrocardiograms, which increase the length of stay in the emergency department.”

Dr. Chang and her colleagues examined 30-day outcomes in a cohort of 568 patients who received CT coronary angiography (CTA) after admission to the ED for chest pain. Half of the patients (285) received their CTA in the ED, with no cardiac markers required; the rest received the procedure after a stay in the observation unit and two or three sets of negative cardiac markers.

All patients had a score of 0–2 on the Thrombolysis in Myocardial Infarction (TIMI) scale. Most patients were black and female; their mean age was 47 years. Hypertension was present in 44% of patients. In two-thirds of patients, the initial electrocardiogram was normal or nonspecific.

Of the 568 patients, 525 had a negative CTA (no lesion of 70% or greater, and a coronary calcium score of less than 100).

In the group of patients who received CTA while in the ED, 81% were discharged home and 19% were admitted, primarily because of confounding medical problems. Stress tests were performed on 13 patients; 2 had positive results and underwent cardiac catheterization. For both of those patients, the catheterization results matched the CTA results; both were medically managed.

In the group that received CTA after an observation unit stay, 97% were discharged home and 3% were admitted. Five patients underwent a stress test, with one positive result. “This patient had a 60% lesion, which was seen on CTA and catheterization, and he received a cardiac stent,” Dr. Chang said at the meeting, which was hosted by the American College of Emergency Physicians.

Most of the cohort with negative CTA results (90%) were contacted by telephone 30 days after discharge. Follow-up on the remainder was performed by a record review and a review of the National Death Index.

The only death resulted from a motor vehicle accident. There were no cardiac deaths, no acute myocardial infarctions, and no revascularizations within the follow-up period.

In addition to accurately identifying those chest pain patients who can be safely discharged from the ED, CTA can also be used as a post-observation-unit discharge strategy, Dr. Chang said.

Studies also show that, compared with stress testing, patients who receive angiography have fewer repeat ED visits and hospitalizations, higher satisfaction with their care, and a better understanding of their disease, Dr. Chang noted.

Patients who receive angiography have fewer repeat ED visits and hospitalizations. DR. CHANG