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Effect of Race on Outcomes Following Early Coronary Computed Tomographic Angiography or Standard Emergency Department Evaluation for Acute Chest Pain.

ABSTRACT: Objective:To examine racial differences in outcomes with coronary computed tomographic angiography (CCTA) vs standard emergency department (ED) evaluation for chest pain. Design:Retrospective analysis of the prospective, randomized, multicenter Rule Out Myocardial Ischemia/Infarction by Computer Assisted Tomography (ROMICAT-II) trial. Setting:ED at nine hospitals in the United States. Participants:940 patients who were Caucasian or African American (AA) presenting to the ED with chest pain. Interventions:CCTA or standard ED evaluation. Main Outcome Measures:Length of stay, hospital admission, direct ED discharge, downstream testing and repeat ED visit or hospitalization for recurrent chest pain at 28 days. Safety end points: missed acute coronary syndrome (ACS) and cumulative radiation exposure during the index visit and follow-up period. Results:659 (66%) patients self-identified as Caucasian and 281 (28%) self-identified as AA. AA were younger and more often female compared with Caucasians, had a higher prevalence of hypertension (64% vs 49%, P<.001) and diabetes (23% vs 14%, P<.001) and a lower prevalence of hyperlipidemia (28% vs 51%, P<.001). ACS was more frequent among Caucasians (10% vs 2%, P<.001). Randomization to CCTA resulted in a reduction in median LOS for Caucasians (7.4 vs 24.7 hours, P<.001) and AA (8.9 vs. 26.3, P<.001; P-interaction=.88). Both AA and Caucasian patients experienced greater radiation exposure and more downstream testing with CCTA compared with standard evaluation. Conclusions:Early CCTA reduced median LOS for both AA and Caucasian patients presenting to the ED with chest pain by approximately 17 hours compared with standard evaluation.

SUBMITTER: Reinhardt SW

PROVIDER: S-EPMC6200301 | biostudies-literature | 2018

REPOSITORIES: biostudies-literature

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Effect of Race on Outcomes Following Early Coronary Computed Tomographic Angiography or Standard Emergency Department Evaluation for Acute Chest Pain.

Reinhardt Samuel W SW Babatunde Adefolakemi A Novak Eric E Brown David L DL

Ethnicity & disease 20181018 4

<h4>Objective</h4>To examine racial differences in outcomes with coronary computed tomographic angiography (CCTA) vs standard emergency department (ED) evaluation for chest pain.<h4>Design</h4>Retrospective analysis of the prospective, randomized, multicenter Rule Out Myocardial Ischemia/Infarction by Computer Assisted Tomography (ROMICAT-II) trial.<h4>Setting</h4>ED at nine hospitals in the United States.<h4>Participants</h4>940 patients who were Caucasian or African American (AA) presenting to ...[more]

PMID: 30405295

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Project description:It is unclear whether an evaluation incorporating coronary computed tomographic angiography (CCTA) is more effective than standard evaluation in the emergency department in patients with symptoms suggestive of acute coronary syndromes.In this multicenter trial, we randomly assigned patients 40 to 74 years of age with symptoms suggestive of acute coronary syndromes but without ischemic electrocardiographic changes or an initial positive troponin test to early CCTA or to standard evaluation in the emergency department on weekdays during daylight hours between April 2010 and January 2012. The primary end point was length of stay in the hospital. Secondary end points included rates of discharge from the emergency department, major adverse cardiovascular events at 28 days, and cumulative costs. Safety end points were undetected acute coronary syndromes.The rate of acute coronary syndromes among 1000 patients with a mean (±SD) age of 54±8 years (47% women) was 8%. After early CCTA, as compared with standard evaluation, the mean length of stay in the hospital was reduced by 7.6 hours (P<0.001) and more patients were discharged directly from the emergency department (47% vs. 12%, P<0.001). There were no undetected acute coronary syndromes and no significant differences in major adverse cardiovascular events at 28 days. After CCTA, there was more downstream testing and higher radiation exposure. The cumulative mean cost of care was similar in the CCTA group and the standard-evaluation group ($4,289 and $4,060, respectively; P=0.65).In patients in the emergency department with symptoms suggestive of acute coronary syndromes, incorporating CCTA into a triage strategy improved the efficiency of clinical decision making, as compared with a standard evaluation in the emergency department, but it resulted in an increase in downstream testing and radiation exposure with no decrease in the overall costs of care. (Funded by the National Heart, Lung, and Blood Institute; ROMICAT-II ClinicalTrials.gov number, NCT01084239.).

Project description:PURPOSE:Quantitative computed tomography (QCT) provides important prognostic information of coronary atherosclerosis. We investigated intraobserver and interobserver QCT reproducibility in asymptomatic individuals, patients with acute chest pain without acute coronary syndrome (ACS), and patients with acute chest pain and ACS. METHODS:Fifty patients from each cohort, scanned between 01/02/2010-14/11/2013 and matched according to age and gender, were retrospectively assessed for inclusion. Patients with no coronary artery disease, previous coronary artery bypass graft surgery, and poor image quality were excluded. Coronary atherosclerosis was measured semi-automatically by 2 readers. Reproducibility of minimal lumen area (MLA), minimal lumen diameter (MLD), area stenosis, diameter stenosis, vessel remodeling, plaque eccentricity, plaque burden, and plaque volumes was assessed using concordance correlation coefficient (CCC), Bland-Altman, coefficient of variation, and Cohen's kappa. RESULTS:A total of 84 patients (63 matched) were included. Intraobserver and interobserver reproducibility estimates were acceptable for MLA (CCC = 0.94 and CCC = 0.91, respectively), MLD (CCC = 0.92 and CCC = 0.86, respectively), plaque burden (CCC = 0.86 and CCC = 0.80, respectively), and plaque volume (CCC = 0.97 and CCC = 0.95, respectively). QCT detected area and diameter stenosis ?50%, positive remodeling, and eccentric plaque with moderate-good intraobserver and interobserver reproducibility (kappa: 0.64-0.66, 0.69-0.76, 0.46-0.48, and 0.41-0.62, respectively). Reproducibility of plaque composition decreased with decreasing plaque density (intraobserver and interobserver CCC for dense calcium (>0.99; 0.98), fibrotic (0.96; 0.93), fibro-fatty (0.95; 0.91), and necrotic core tissue (0.89; 0.84). Reproducibility generally decreased with worsening clinical risk profile. CONCLUSIONS:Semi-automated QCT of coronary plaque morphology is reproducible, albeit with some decline in reproducibility with worsening patient risk profile.

Dataset Information

Effect of Race on Outcomes Following Early Coronary Computed Tomographic Angiography or Standard Emergency Department Evaluation for Acute Chest Pain.

Publications

Effect of Race on Outcomes Following Early Coronary Computed Tomographic Angiography or Standard Emergency Department Evaluation for Acute Chest Pain.

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