Clinical implementation of an emergency department coronary computed tomographic angiography protocol for triage of patients with suspected acute coronary syndrome

on behalf of MGH Emergency Cardiac CTA Program Contributors

Research output: Contribution to journalArticle

15 Citations (Scopus)

Abstract

Objectives: To evaluate the efficiency and safety of emergency department (ED) coronary computed tomography angiography (CTA) during a 3-year clinical experience. Methods: Single-center registry of coronary CTA in consecutive ED patients with suspicion of acute coronary syndrome (ACS). The primary outcome was efficiency of coronary CTA defined as the length of hospitalization. Secondary endpoints of safety were defined as the rate of downstream testing, normalcy rates of invasive coronary angiography (ICA), absence of missed ACS, and major adverse cardiac events (MACE) during follow-up, and index radiation exposure. Results: One thousand twenty two consecutive patients were referred for clinical coronary CTA with suspicion of ACS. Overall, median time to discharge home was 10.5 (5.7-24.1) hours. Patient disposition was 42.7 % direct discharge from the ED, 43.2 % discharge from emergency unit, and 14.1 % hospital admission. ACS rate during index hospitalization was 9.1 %. One hundred ninety two patients underwent additional diagnostic imaging and 77 underwent ICA. The positive predictive value of CTA compared to ICA was 78.9 % (95 %-CI 68.1-87.5 %). Median CT radiation exposure was 4.0 (2.5-5.8) mSv. No ACS was missed; MACE at follow-up after negative CTA was 0.2 %. Conclusions: Coronary CTA in an experienced tertiary care setting allows for efficient and safe management of patients with suspicion for ACS. Key points: • ED Coronary CTA using advanced systems is associated with low radiation exposure.• Negative coronary CTA is associated with low rates of MACE.• CTA in ED patients enables short median time to discharge home.• CTA strategy is characterized by few downstream tests including unnecessary ICA.

Original languageEnglish (US)
Pages (from-to)1-10
Number of pages10
JournalEuropean Radiology
DOIs
StateAccepted/In press - Nov 24 2016

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Triage
Acute Coronary Syndrome
Hospital Emergency Service
Angiography
Coronary Angiography
Hospitalization
Computed Tomography Angiography
Safety
Diagnostic Imaging
Tertiary Healthcare
Registries

Keywords

  • Cardiovascular diseases
  • Coronary artery disease
  • Emergency service
  • Hospital
  • Length of stay
  • Multidetector computed tomography

ASJC Scopus subject areas

  • Radiology Nuclear Medicine and imaging

Cite this

Clinical implementation of an emergency department coronary computed tomographic angiography protocol for triage of patients with suspected acute coronary syndrome. / on behalf of MGH Emergency Cardiac CTA Program Contributors.

In: European Radiology, 24.11.2016, p. 1-10.

Research output: Contribution to journalArticle

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title = "Clinical implementation of an emergency department coronary computed tomographic angiography protocol for triage of patients with suspected acute coronary syndrome",
abstract = "Objectives: To evaluate the efficiency and safety of emergency department (ED) coronary computed tomography angiography (CTA) during a 3-year clinical experience. Methods: Single-center registry of coronary CTA in consecutive ED patients with suspicion of acute coronary syndrome (ACS). The primary outcome was efficiency of coronary CTA defined as the length of hospitalization. Secondary endpoints of safety were defined as the rate of downstream testing, normalcy rates of invasive coronary angiography (ICA), absence of missed ACS, and major adverse cardiac events (MACE) during follow-up, and index radiation exposure. Results: One thousand twenty two consecutive patients were referred for clinical coronary CTA with suspicion of ACS. Overall, median time to discharge home was 10.5 (5.7-24.1) hours. Patient disposition was 42.7 {\%} direct discharge from the ED, 43.2 {\%} discharge from emergency unit, and 14.1 {\%} hospital admission. ACS rate during index hospitalization was 9.1 {\%}. One hundred ninety two patients underwent additional diagnostic imaging and 77 underwent ICA. The positive predictive value of CTA compared to ICA was 78.9 {\%} (95 {\%}-CI 68.1-87.5 {\%}). Median CT radiation exposure was 4.0 (2.5-5.8) mSv. No ACS was missed; MACE at follow-up after negative CTA was 0.2 {\%}. Conclusions: Coronary CTA in an experienced tertiary care setting allows for efficient and safe management of patients with suspicion for ACS. Key points: • ED Coronary CTA using advanced systems is associated with low radiation exposure.• Negative coronary CTA is associated with low rates of MACE.• CTA in ED patients enables short median time to discharge home.• CTA strategy is characterized by few downstream tests including unnecessary ICA.",
keywords = "Cardiovascular diseases, Coronary artery disease, Emergency service, Hospital, Length of stay, Multidetector computed tomography",
author = "{on behalf of MGH Emergency Cardiac CTA Program Contributors} and Ghoshhajra, {Brian B.} and Takx, {Richard A P} and Staziaki, {Pedro V.} and Harshna Vadvala and Phillip Kim and Neilan, {Tomas G.} and Meyersohn, {Nandini M.} and Daniel Bittner and Janjua, {Sumbal A.} and Thomas Mayrhofer and Greenwald, {Jeffrey L.} and Truong, {Quyhn A.} and Suhny Abbara and Brown, {David F M} and Januzzi, {James L.} and Sanjeev Francis and Nagurney, {John T.} and Udo Hoffmann and Andy Chan and Garry Choy and Rajiv Gupta and Mannudeep Kalra and Ali Karaosmanoglu and Levesque, {Marie Helene} and Lu, {Michael T.} and Oliveira, {George R.} and Prabhakar, {Anand M.} and Naveen Kulkarni and Peterson, {Paul Gabriel} and Jonathan Scheske and Parmanand Singh and Amit Pursnani and Marcello Panagia and Karl Sayegh and Umesh Sharma and Christopher Walker and Stacey Verzosa",
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AU - on behalf of MGH Emergency Cardiac CTA Program Contributors

AU - Ghoshhajra, Brian B.

AU - Takx, Richard A P

AU - Staziaki, Pedro V.

AU - Vadvala, Harshna

AU - Kim, Phillip

AU - Neilan, Tomas G.

AU - Meyersohn, Nandini M.

AU - Bittner, Daniel

AU - Janjua, Sumbal A.

AU - Mayrhofer, Thomas

AU - Greenwald, Jeffrey L.

AU - Truong, Quyhn A.

AU - Abbara, Suhny

AU - Brown, David F M

AU - Januzzi, James L.

AU - Francis, Sanjeev

AU - Nagurney, John T.

AU - Hoffmann, Udo

AU - Chan, Andy

AU - Choy, Garry

AU - Gupta, Rajiv

AU - Kalra, Mannudeep

AU - Karaosmanoglu, Ali

AU - Levesque, Marie Helene

AU - Lu, Michael T.

AU - Oliveira, George R.

AU - Prabhakar, Anand M.

AU - Kulkarni, Naveen

AU - Peterson, Paul Gabriel

AU - Scheske, Jonathan

AU - Singh, Parmanand

AU - Pursnani, Amit

AU - Panagia, Marcello

AU - Sayegh, Karl

AU - Sharma, Umesh

AU - Walker, Christopher

AU - Verzosa, Stacey

PY - 2016/11/24

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N2 - Objectives: To evaluate the efficiency and safety of emergency department (ED) coronary computed tomography angiography (CTA) during a 3-year clinical experience. Methods: Single-center registry of coronary CTA in consecutive ED patients with suspicion of acute coronary syndrome (ACS). The primary outcome was efficiency of coronary CTA defined as the length of hospitalization. Secondary endpoints of safety were defined as the rate of downstream testing, normalcy rates of invasive coronary angiography (ICA), absence of missed ACS, and major adverse cardiac events (MACE) during follow-up, and index radiation exposure. Results: One thousand twenty two consecutive patients were referred for clinical coronary CTA with suspicion of ACS. Overall, median time to discharge home was 10.5 (5.7-24.1) hours. Patient disposition was 42.7 % direct discharge from the ED, 43.2 % discharge from emergency unit, and 14.1 % hospital admission. ACS rate during index hospitalization was 9.1 %. One hundred ninety two patients underwent additional diagnostic imaging and 77 underwent ICA. The positive predictive value of CTA compared to ICA was 78.9 % (95 %-CI 68.1-87.5 %). Median CT radiation exposure was 4.0 (2.5-5.8) mSv. No ACS was missed; MACE at follow-up after negative CTA was 0.2 %. Conclusions: Coronary CTA in an experienced tertiary care setting allows for efficient and safe management of patients with suspicion for ACS. Key points: • ED Coronary CTA using advanced systems is associated with low radiation exposure.• Negative coronary CTA is associated with low rates of MACE.• CTA in ED patients enables short median time to discharge home.• CTA strategy is characterized by few downstream tests including unnecessary ICA.

AB - Objectives: To evaluate the efficiency and safety of emergency department (ED) coronary computed tomography angiography (CTA) during a 3-year clinical experience. Methods: Single-center registry of coronary CTA in consecutive ED patients with suspicion of acute coronary syndrome (ACS). The primary outcome was efficiency of coronary CTA defined as the length of hospitalization. Secondary endpoints of safety were defined as the rate of downstream testing, normalcy rates of invasive coronary angiography (ICA), absence of missed ACS, and major adverse cardiac events (MACE) during follow-up, and index radiation exposure. Results: One thousand twenty two consecutive patients were referred for clinical coronary CTA with suspicion of ACS. Overall, median time to discharge home was 10.5 (5.7-24.1) hours. Patient disposition was 42.7 % direct discharge from the ED, 43.2 % discharge from emergency unit, and 14.1 % hospital admission. ACS rate during index hospitalization was 9.1 %. One hundred ninety two patients underwent additional diagnostic imaging and 77 underwent ICA. The positive predictive value of CTA compared to ICA was 78.9 % (95 %-CI 68.1-87.5 %). Median CT radiation exposure was 4.0 (2.5-5.8) mSv. No ACS was missed; MACE at follow-up after negative CTA was 0.2 %. Conclusions: Coronary CTA in an experienced tertiary care setting allows for efficient and safe management of patients with suspicion for ACS. Key points: • ED Coronary CTA using advanced systems is associated with low radiation exposure.• Negative coronary CTA is associated with low rates of MACE.• CTA in ED patients enables short median time to discharge home.• CTA strategy is characterized by few downstream tests including unnecessary ICA.

KW - Cardiovascular diseases

KW - Coronary artery disease

KW - Emergency service

KW - Hospital

KW - Length of stay

KW - Multidetector computed tomography

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