Coronary Computed Tomography Angiography for Assessment of Suspected Acute Coronary Syndrome in the Emergency Department

Background: Chest pain is a common chief symptom in the emergency department (ED). Acute coronary syndrome (ACS) is a critical diagnosis and, when missed, is associated with adverse patient outcomes and is frequently associated with malpractice claims. Coronary computed tomography angiography (cCTA) is increasingly available to ED patients and it may aid in diagnosis of ACS. Clinical Question: In adults presenting to the ED with suspected ACS, does cCTA during ED evaluation improve patient-centered outcomes compared with standard interventions, such as clinical gestalt, the HEART score/pathway, and nonimaging disposition strategies? Evidence Review: Three studies were reviewed, including a before-and-after retrospective study, a randomized controlled trial, and a systematic review, in addition to consensus recommendations from the Society of Cardiovascular Computed Tomography, American College of Radiology, and North American Society for Cardiovascular Imaging. Conclusions: Compared with current ED management strategies for suspected ACS, routinely ordering cCTA for patients with chest pain does not improve 1-year cardiac outcomes, reduce admissions, or return visits. However, among low-risk (< 10% baseline risk) patients with ACS, cCTA reduces hospital length of stay and lower costs while increasing revascularization rates. Ultimately, targeting cCTA for patients at higher short-term risk for major adverse cardiovascular events and limited access to invasive cardiac catheterization laboratories may prove to be more efficacious and cost-effective.