Coronary CTA (CCTA) in Emergency Department Patients

JC sadly but dutifully announces the need to return to our virtual format for our last meeting of 2020. The Covid-19 rates in our part of VA unfortunately, are increasing (currently11%) and we must consider everyone’s safety first. Hopefully, we will be able to have an in-person JC in January and get back to enjoying each other’s company. On a much more positive note, I am happy to announce that Drs. Mohit Bhasin and Chris Maroules both CCTA experts, will be co-moderating and help us interpret the current data on CCTA’s as well as field the many questions that have come up as we attempt to implement a strategy for effective use in our ED’s.    

Interestingly, CCTA’s have been around for quite some time. In fact, in 2012 we looked at the topic at JC and for a short time were utilizing the technology in some of our ED patients. Some of our barriers at the time included availability of “expert” CCTA interpreting clinicians, the need for a more supportive institutional infrastructure, non-reimbursement from insurance companies and higher ED LOS’s. From an EBM perspective there was evidence of very high sensitivity of CCTA, but concerns included limited external validity, an increase in downstream diagnostic testing and potential harms from radiation exposure.     

Since then, we have had additional data which were selected for review by our co-moderators and will be appraised by our presenters. Additionally, in the UK, the National Institute for Health and Care Excellence (NICE) routinely reviews clinical evidence and publishes advice and recommendations based on the combination of clinical efficacy and cost effectiveness of therapies and technologies. They are incredibly rigorous in their assessment of the data and economic impact on the National Health Plan in the UK and I was truly impressed to see the following statement included in their most recent NICE update on CCTA: “The low cost and high sensitivity of cardiac CT makes it the non-invasive test of choice in the evaluation of stable angina.”

 Linde J, et al. Long-Term Clinical Impact of Coronary CT Angiography in Patients With Recent Acute-Onset Chest Pain: The Randomized Controlled CATCH Trial ACC Cardiovasc Imaging 2015 Dec;8(12):1404-1413. Appraisal

Burris A, et al.  Triple Rule Out Versus Coronary CT Angiography in Patients With Acute Chest Pain: Results From the ACIC Consortium JACC Cardiovasc Imaging 2015 Jul;8(7):817-25 Appraisal

Newby D, et al.  Coronary CT Angiography and 5-Year Risk of Myocardial Infarction. SCOT-HEART Investigators. N Engl J Med. 2018 Sep 6;379 (10):924-933 Appraisal

Moss A, et al. The Updated NICE Guidelines: Cardiac CT as the First-Line Test for Coronary Artery Disease Curr Cardiovasc Imaging Rep 2017;10(5):15.