Coronary CT Angiography Versus Standard Emergency Department Evaluation for Acute Chest Pain and Diabetic Patients: Is There Benefit With Early Coronary CT Angiography? Results of the Randomized Comparative Effectiveness ROMICAT II Trial

Quynh A Truong, Joshua Schulman-Marcus, Pearl Zakroysky, Eric T Chou, John T Nagurney, Jerome L Fleg, David A Schoenfeld, James E Udelson, Udo Hoffmann, Pamela K Woodard, Quynh A Truong, Joshua Schulman-Marcus, Pearl Zakroysky, Eric T Chou, John T Nagurney, Jerome L Fleg, David A Schoenfeld, James E Udelson, Udo Hoffmann, Pamela K Woodard

Abstract

Background: Cardiac computed tomography angiography (CCTA) reduces emergency department length of stay compared with standard evaluation in patients with low- and intermediate-risk acute chest pain. Whether diabetic patients have similar benefits is unknown.

Methods and results: In this prespecified analysis of the Rule Out Myocardial Ischemia/Infarction by Computer Assisted Tomography (ROMICAT II) multicenter trial, we randomized 1000 patients (17% diabetic) with symptoms suggestive of acute coronary syndrome to CCTA or standard evaluation. The rate of acute coronary syndrome was 8% in both diabetic and nondiabetic patients (P=1.0). Length of stay was unaffected by the CCTA strategy for diabetic patients (23.9 versus 27.2 hours, P=0.86) but was reduced for nondiabetic patients compared with standard evaluation (8.4 versus 26.5 hours, P<0.0001; P interaction=0.004). CCTA resulted in 3-fold more direct emergency department discharge in both groups (each P≤0.0001, P interaction=0.27). No difference in hospital admissions was seen between the 2 strategies in diabetic and nondiabetic patients (P interaction=0.09). Both groups had more downstream testing and higher radiation doses with CCTA, but these were highest in diabetic patients (all P interaction≤0.04). Diabetic patients had fewer normal CCTAs than nondiabetic patients (32% versus 50%, P=0.003) and similar normalcy rates with standard evaluation (P=0.70). Notably, 66% of diabetic patients had no or mild stenosis by CCTA with short length of stay comparable to that of nondiabetic patients (P=0.34), whereas those with >50% stenosis had a high prevalence of acute coronary syndrome, invasive coronary angiography, and revascularization.

Conclusions: Knowledge of coronary anatomy with CCTA is beneficial for diabetic patients and can discriminate between lower risk patients with no or little coronary artery disease who can be discharged immediately and higher risk patients with moderate to severe disease who warrant further workup.

Clinical trial registration: URL: https://www.clinicaltrials.gov/. Unique identifier: NCT01084239.

Keywords: acute coronary syndrome; cardiac computed tomography; chest pain diagnosis; diabetes mellitus; emergency department.

© 2016 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley Blackwell.

Figures

Figure 1
Figure 1
Length of stay for patients with no or mild coronary atherosclerosis (

References

    1. Stone NJ, Robinson JG, Lichtenstein AH, Bairey Merz CN, Blum CB, Eckel RH, Goldberg AC, Gordon D, Levy D, Lloyd‐Jones DM, McBride P, Schwartz JS, Shero ST, Smith SC Jr, Watson K, Wilson PW, Eddleman KM, Jarrett NM, LaBresh K, Nevo L, Wnek J, Anderson JL, Halperin JL, Albert NM, Bozkurt B, Brindis RG, Curtis LH, DeMets D, Hochman JS, Kovacs RJ, Ohman EM, Pressler SJ, Sellke FW, Shen WK, Smith SC Jr, Tomaselli GF; American College of Cardiology/American Heart Association Task Force on Practice G . 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014;129:S1–S45.
    1. Howard BV, Best LG, Galloway JM, Howard WJ, Jones K, Lee ET, Ratner RE, Resnick HE, Devereux RB. Coronary heart disease risk equivalence in diabetes depends on concomitant risk factors. Diabetes Care. 2006;29:391–397.
    1. Lopez‐Jimenez F, Goldman L, Johnson PA, Polanczyk CA, Cook EF, Fleischmann KE, Orav EJ, Lee TH. Effect of diabetes mellitus on the presentation and triage of patients with acute chest pain without known coronary artery disease. Am J Med. 1998;105:500–505.
    1. Jayes RL Jr, Beshansky JR, D'Agostino RB, Selker HP. Do patients’ coronary risk factor reports predict acute cardiac ischemia in the emergency department? A multicenter study J Clin Epidemiol. 1992;45:621–626.
    1. Han JH, Lindsell CJ, Storrow AB, Luber S, Hoekstra JW, Hollander JE, Peacock WF IV, Pollack CV, Gibler WB; Investigators Eit . The role of cardiac risk factor burden in diagnosing acute coronary syndromes in the emergency department setting. Ann Emerg Med. 2007;49:145–152, 152.e141.
    1. Body R, McDowell G, Carley S, Mackway‐Jones K. Do risk factors for chronic coronary heart disease help diagnose acute myocardial infarction in the Emergency Department? Resuscitation. 2008;79:41–45.
    1. Hoffmann U, Truong QA, Schoenfeld DA, Chou ET, Woodard PK, Nagurney JT, Pope JH, Hauser TH, White CS, Weiner SG, Kalanjian S, Mullins ME, Mikati I, Peacock WF, Zakroysky P, Hayden D, Goehler A, Lee H, Gazelle GS, Wiviott SD, Fleg JL, Udelson JE; Investigators R‐I . Coronary CT angiography versus standard evaluation in acute chest pain. N Engl J Med. 2012;367:299–308.
    1. Litt HI, Gatsonis C, Snyder B, Singh H, Miller CD, Entrikin DW, Leaming JM, Gavin LJ, Pacella CB, Hollander JE. CT angiography for safe discharge of patients with possible acute coronary syndromes. N Engl J Med. 2012;366:1393–1403.
    1. Goldstein JA, Chinnaiyan KM, Abidov A, Achenbach S, Berman DS, Hayes SW, Hoffmann U, Lesser JR, Mikati IA, O'Neil BJ, Shaw LJ, Shen MY, Valeti US, Raff GL. The CT‐STAT (Coronary Computed Tomographic Angiography for Systematic Triage of Acute Chest Pain Patients to Treatment) trial. J Am Coll Cardiol. 2011;58:1414–1422.
    1. Truong QA, Hayden D, Woodard PK, Kirby R, Chou ET, Nagurney JT, Wiviott SD, Fleg JL, Schoenfeld DA, Udelson JE, Hoffmann U. Sex differences in the effectiveness of early coronary computed tomographic angiography compared with standard emergency department evaluation for acute chest pain: the rule‐out myocardial infarction with Computer‐Assisted Tomography (ROMICAT)‐II Trial. Circulation. 2013;127:2494–2502.
    1. Hoffmann U, Truong QA, Fleg JL, Goehler A, Gazelle S, Wiviott S, Lee H, Udelson JE, Schoenfeld D; ROMICAT II . Design of the Rule Out Myocardial Ischemia/Infarction Using Computer Assisted Tomography: a multicenter randomized comparative effectiveness trial of cardiac computed tomography versus alternative triage strategies in patients with acute chest pain in the emergency department. Am Heart J. 2012;163:330–338, 338.e331.
    1. Gerber TC, Carr JJ, Arai AE, Dixon RL, Ferrari VA, Gomes AS, Heller GV, McCollough CH, McNitt‐Gray MF, Mettler FA, Mieres JH, Morin RL, Yester MV. Ionizing radiation in cardiac imaging: a science advisory from the American Heart Association Committee on Cardiac Imaging of the Council on Clinical Cardiology and Committee on Cardiovascular Imaging and Intervention of the Council on Cardiovascular Radiology and Intervention. Circulation. 2009;119:1056–1065.
    1. Udelson JE, Beshansky JR, Ballin DS, Feldman JA, Griffith JL, Handler J, Heller GV, Hendel RC, Pope JH, Ruthazer R, Spiegler EJ, Woolard RH, Selker HP. Myocardial perfusion imaging for evaluation and triage of patients with suspected acute cardiac ischemia: a randomized controlled trial. JAMA. 2002;288:2693–2700.
    1. Kapetanopoulos A, Heller GV, Selker HP, Ruthazer R, Beshansky JR, Feldman JA, Griffith JL, Hendel RC, Pope JH, Spiegler EJ, Udelson JE. Acute resting myocardial perfusion imaging in patients with diabetes mellitus: results from the Emergency Room Assessment of Sestamibi for Evaluation of Chest Pain (ERASE Chest Pain) trial. J Nucl Cardiol. 2004;11:570–577.
    1. Rana JS, Dunning A, Achenbach S, Al‐Mallah M, Budoff MJ, Cademartiri F, Callister TQ, Chang H‐J, Cheng VY, Chinnaiyan K, Chow BJW, Cury R, Delago A, Feuchtner G, Hadamitzky M, Hausleiter J, Kaufmann P, Karlsberg RP, Kim Y‐J, Leipsic J, Labounty TM, Lin FY, Maffei E, Raff G, Villines TC, Shaw LJ, Berman DS, Min JK. Differences in prevalence, extent, severity, and prognosis of coronary artery disease among patients with and without diabetes undergoing coronary computed tomography angiography: results from 10,110 individuals from the CONFIRM (COronary CT Angiography EvaluatioN For Clinical Outcomes): an InteRnational Multicenter Registry. Diabetes Care. 2012;35:1787–1794.
    1. de Araujo Goncalves P, Garcia‐Garcia HM, Carvalho MS, Dores H, Sousa PJ, Marques H, Ferreira A, Cardim N, Teles RC, Raposo L, Gabriel HM, Almeida M, Aleixo A, Carmo MM, Machado FP, Mendes M. Diabetes as an independent predictor of high atherosclerotic burden assessed by coronary computed tomography angiography: the coronary artery disease equivalent revisited. Int J Cardiovasc Imaging. 2013;29:1105–1114.
    1. Kamimura M, Moroi M, Isobe M, Hiroe M. Role of coronary CT angiography in asymptomatic patients with type 2 diabetes mellitus. Int Heart J. 2012;53:23–28.
    1. Achenbach S, Marwan M, Ropers D, Schepis T, Pflederer T, Anders K, Kuettner A, Daniel WG, Uder M, Lell MM. Coronary computed tomography angiography with a consistent dose below 1 mSv using prospectively electrocardiogram‐triggered high‐pitch spiral acquisition. Eur Heart J. 2010;31:340–346.
    1. Deseive S, Pugliese F, Meave A, Alexanderson E, Martinoff S, Hadamitzky M, Massberg S, Hausleiter J. Image quality and radiation dose of a prospectively electrocardiography‐triggered high‐pitch data acquisition strategy for coronary CT angiography: the multicenter, randomized PROTECTION IV study. J Cardiovasc Comput Tomogr. 2015;9:278–285.

Source: PubMed

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