Washington University Emergency Medicine Journal Club – October 2025
Hello all,
This month’s journal club will look at the use of CCTA (coronary CT angiogram) for low to moderate risk patients in the emergency department. Dr. Peter Fletcher will be joining us to help lead the discussion.
The PGY-1, PGY-3, and PGY-4 papers will be appraised using the Therapy review form.
The PGY-2 paper will be appraised using the Meta-Analysis review form.
Vignette
You are working at Barnes-Jewish West County Hospital. It’s Monday morning at 7 a.m. You walk in, waving hello to the boarding patient you signed out yesterday.
The first patient you see is a 43-year-old man with a history of hypertension and hyperlipidemia. He reports waking up around 2 a.m. with chest discomfort. He went back to bed and, half-jokingly, says he was surprised to wake up still alive. The chest pain persisted but steadily improved, and he is now pain-free. He adds that he probably would have thought nothing of it, except his father had a heart attack at age 43—and today happens to be his birthday.
You obtain a 12-lead EKG, which shows sinus rhythm at a rate of 79 and a left bundle branch block that appears unchanged from one documented two years ago at his PCP’s office. His initial troponin is 8, chest X-ray is clear, and remaining labs are within normal limits. He has no known history of CAD and has never had stress testing.
You assign him a HEART score of 4 based on risk factors and EKG. His 2-hour troponin results at 9, with an insignificant delta. Reviewing the HEART Pathway, you consider transferring him to MBMC for stress testing.
As you walk past your boarder from the night before, you glance at the tracking board—12 patients are waiting. You wonder to yourself: is there a way to safely evaluate for obstructive coronary artery disease here? Didn’t Coronary CTA used to be a thing? Could that be used to help avoid a transfer or admission?
PICO Questions
Population: Low-to-moderate risk chest pain patients presenting to the ED
Intervention: CT coronary angiography
Comparison: Routine risk stratification and coronary care, including stress testing
Outcome: Coronary artery disease diagnostic accuracy, ED length-of-stay,
hospitalization rates and length-of-stay, radiation exposure, contrast reactions,
short-term and long-term cardiac-mortality, and cost
Article 1: Hoffmann U, Truong QA, Schoenfeld DA, et al; ROMICAT-II Investigators.
Coronary CT angiography versus standard evaluation in acute chest pain. N Engl J
Med. 2012 Jul 26;367(4):299-308. [Answer Key].
Article 2: Barbosa MF, Canan A, Xi Y, et al. Comparative Effectiveness of Coronary CT
Angiography and Standard of Care for Evaluating Acute Chest Pain: A Living
Systematic Review and Meta-Analysis. Radiol Cardiothorac Imaging. 2023 Aug
24;5(4):e230022. [Answer Key].
Article 3: Litt HI, Gatsonis C, Snyder B, et al. CT angiography for safe discharge of
patients with possible acute coronary syndromes. N Engl J Med. 2012 Apr
12;366(15):1393-403. [Answer Key].
Article 4: Goldstein JA, Chinnaiyan KM, Abidov A, et al; CT-STAT Investigators. The
CT-STAT (Coronary Computed Tomographic Angiography for Systematic Triage of
Acute Chest Pain Patients to Treatment) trial. J Am Coll Cardiol. 2011 Sep
27;58(14):1414-22. [Answer Key].
Bottom Line
The use of CT coronary angiography (CCTA) to evaluate for coronary artery disease was first studied in the early 2000s. While diagnostic accuracy has improved as technology has developed over time, the ED management of chest pain has changed as well as new clinical decision rules (e.g. the HEART score) and high-sensitivity troponin assays have been introduced. In order to update our understanding of the safety and efficacy of CCTA in the evaluation of chest pain, four studies comparing CCTA against standard care (SOC) or rest-stress myocardial perfusion imaging (MPI) for evaluating acute chest pain (ACP) were reviewed.
The ROMICAT-II trial was a multi-center randomized controlled trial (RCT) involving 1000 patients aged 40-74 years presenting with chest pain. It compared the outcomes of CCTA to standard ED evaluation and demonstrated that CCTA significantly shortened the mean hospital length of stay by 7.6 hours (p < 0.001) and led to higher discharge rates from the ED (50% discharged within 8.6 hours versus 10% with standard care). Additionally, fewer patients were admitted in the CCTA group (47% vs. 12%; p<0.001). However, CCTA resulted in increased radiation exposure (mean 13.9 mSv vs. 4.7 mSv) and more diagnostic testing and treatment, including invasive coronary angiography (11% vs. 7%) and coronary revascularization (5% vs. 3%) . Safety outcomes showed no undetected acute coronary syndromes post-discharge and comparable major adverse cardiovascular events (MACE) within 28 days between the groups.
Another multi-center RCT involving 1370 patients assessed the safety of CCTA against traditional care in evaluating suspected ACS in patients with with a Thrombolysis in Myocardial Infarction (TIMI) risk score of 0 to 2. For the primary outcome, there were no deaths or myocardial infarctions within 30 days among 640 patients with negative CCTA (0%; 95% CI 0 to 0.57).The CCTA group showed higher discharge rates from the ED (49.6% vs. 22.7%; difference 26.8%, 95% CI: 21.4% to 32.2%) and had a shorter median length of stay (median 18 vs. 24.8 hours). Coronary artery disease was diagnosed more frequently in the CCTA group (9.0% vs. 3.5%). At 30-day follow-up, no significant differences were observed in invasive coronary angiography (5.1% vs. 4.2%), revascularization rates (2.7% vs. 1.3%), or repeat ED visits. No deaths or late ACS occurred in either group, underscoring the safety of CCTA in this setting.
The CT-STAT trial was another multi-center RCT comparing CCTA to MPI for evaluating acute low-risk chest pain. Patients with a TIMI risk score ≤4 were enrolled from 16 sites in the US. Among 699 patients with complete follow-up, CCTA achieved a faster median diagnosis time (2.9 hours vs. 6.2 hours; 54% faster diagnosis with CCTA, p < 0.0001) and lower ED costs ($2,137 vs. $3,458). Radiation exposure was slightly lower for CCTA (11.5 mSv vs. 12.8 mSv). Both groups had similar six-month rates of MACE, with no deaths or late ACS in either group. CCTA showed comparable safety profiles to MPI.
A systematic review and meta-analysis using the Nested Knowledge living review platform included 22 randomized controlled trials with 9379 participants. And evaluated CCTA versus SOC in the evaluation of acute chest pain. Pooled results indicated a 14% (95% CI 5% to 22%) reduction in hospital length of stay for CCTA as well as a 17% reduction in costs (95% CI 5% to 28%). While there was an increase in revascularization procedures in the CCTA group among low-to-intermediate risk patients (RR 1.45; 95% CI 1.09 to 1.93), but no significant differences were found in rates of MI all-cause mortality, or radiation exposure. Medication changes were more frequent with CCTA, mainly in low-to-intermediate risk patients.
Together, these studies highlight CCTA’s efficiency in improving diagnostic speed and discharge rates, with similar safety outcomes compared to SOC and MPI, albeit with some increased use of resources and radiation exposure. It should be noted that many of the relevant studies included patients with low TIMI scores, in whom the risk of of a adverse event is quite low. There has been increasing evidence since the inception of these studies that such testing in low risk patients is often not beneficial (Foy 2015, Redberg 2015). Additionally, rates of provocative testing among patients presenting to the ED with chest pain have fallen significantly over the last 15 years, in part due to the introduction of high-sensitivity troponins (Contractor 2021), and it is unclear how these changes would impact the findings in this study. Further research would help improve our understanding of the impact of CCTA in the current climate of ED management of chest pain.