By Dr. Jonathan Shurlock, edited by Dr. Ahmed El-Medany
Chest pain remains a common presentation to emergency departments and many of these patients end up on a pathway of attempting to rule out an acute coronary syndrome. At present this approach can require multiple blood tests to assess trends in high-sensitivity troponin concentrations. The authors of the Prospective RandOmised Trial of Emergency Cardiac Computerised Tomography (PROTECCT) trial have set out to explore the role of CT coronary angiography (CTCA) in this setting, in those individuals with initial high sensitivity troponin values between rule-in and rule-out thresholds.
The primary outcome measure was length of hospital stay from presentation to discharge or death. Secondary outcomes included MACE, cost of inpatient stay and rates of invasive coronary angiography.
250 patients were randomised (aged 55 ±14 years) to receiving CTCA or standard of care (SOC). There was no significant difference in length of stay (LOS) between the two groups 7.53 hours (6.0–9.6) CTCA arm and 8.14 (6.3–9.8) hours SOC arm (p=0.13). In sub-group analysis the length of stay for patients with <25% stenoses was significant shorted than for those with mild (25%) or greater stenoses (6.6 (5.6–7.8) hours vs 8.8 (6.5–10.7) hours; p<0.005)
In conclusion the study found that CTCA did not lead to reduced hospital LOS or cost. The authors hypothesise two reasons for this. The first was that no CAD on CTCA gave clinicians the confidence to discharge early, while any presence of mild or worse CAD compounded the ambiguity caused by an indeterminate initial high sensitivity troponin value. The second being that CTCA interpretation and subsequent decision making was left to the discretion of the responsible clinician, rather than being didactic. While this may have slowed decision making they acknowledge that this is more reflective of real world practice.
See the full study here: https://heart.bmj.com/content/early/2022/10/26/heartjnl-2022-320990?rss=1