Incorporating CT Coronary Angiography in the Acute Chest Pain Pathway—An Efficient Model of Resource Utilization

Abstract

Background: CT coronary angiography (CTCA) is increasingly used in the settings of acute chest pain, due to its excellent negative predictive value. Its impact on downstream resource utilisation is unclear, however. Methods: CTCA was incorporated into the acute chest pain management pathway, either prior to or after exercise ECG, at the discretion of general physicians and cardiologists, based on perceived intermediate pre-test probability of coronary artery disease (CAD). Patients with known coronary artery disease were excluded. Imaging on the 320-slice scanner (Aquillon ONE, Toshiba Medical Systems) averaged a radiation dose of 4.1 ± 2.3 mSv. Results: In the first six months (n = 274, age 56 ± 10, BMI 29 ± 6), CTCA either preceded exercise ECG (n = 181) or followed equivocal exercise ECG (n = 93). The two groups did not differ in the angina history (typical 32%, atypical 50%, non-cardiac 18%) or prevalence of risk factors. The prevalence of obstructive coronary disease and non-obstructive atherosclerosis was 19% and 37% respectively, with no difference between the groups (p = 0.08). In those who had prior equivocal stress ECG, 18 patients (20%) proceeded to coronary catheterisation. In those who had no prior stress testing, 26 patients (15%) underwent catheterization. Of those, 48% were prioritised on the outpatient list. Conclusion: Incorporating CTCA in the acute chest pain pathway is efficient in avoiding catheterisation in 80% of patients who had equivocal stress testing. In those who had CTCA prior to any stress testing, catheterisation rate is low at 15%.