Prospective RandOmised Trial of Emergency Cardiac Computerised Tomography (PROTECCT)

Coronary Artery Disease: Role of Computed Tomography and Recent Advances

In this review, the authors summarize the role of coronary computed tomography angiography and coronary artery calcium scoring in different clinical presentations of chest pain and preventative care and discuss future directions and new technologies such as pericoronary fat inflammation and the growing footprint of artificial intelligence in cardiovascular medicine.

Role of computed tomography cardiac angiography in acute chest pain syndromes

Use of CT coronary angiography (CTCA) to evaluate chest pain has rapidly increased over the recent years. While its utility in the diagnosis of coronary artery disease in stable chest pain syndromes is clear and is strongly endorsed by international guidelines, the role of CTCA in the acute setting is less certain. In the low-risk setting, CTCA has been shown to be accurate, safe and efficient but inherent low rates of adverse events in this population and the advent of high-sensitivity troponin testing have left little room for CTCA to show any short-term clinical benefit.In higher-risk populations, CTCA has potential to fulfil a gatekeeper role to invasive angiography. The high negative predictive value of CTCA is maintained while also identifying non-obstructive coronary disease and alternative diagnoses in the substantial group of patients presenting with chest pain who do not have type 1 myocardial infarction. For those with obstructive coronary disease, CTCA provides accurate assessment of stenosis severity, characterisation of high-risk plaque and findings associated with perivascular inflammation. This may allow more appropriate selection of patients to proceed to invasive management with no disadvantage in outcomes and can provide a more comprehensive risk stratification to guide both acute and long-term management than routine invasive angiography.

Comparative Effectiveness of Coronary CT Angiography and Standard of Care for Evaluating Acute Chest Pain: A Living Systematic Review and Meta-Analysis

Purpose

To perform a living systematic review and meta-analysis of randomized controlled trials comparing the effectiveness of coronary CT angiography (CCTA) and standard of care (SOC) in the evaluation of acute chest pain (ACP).

Materials and Methods

Multiple electronic databases were systematically searched, with the most recent search conducted on October 31, 2022. Studies were stratified into two groups according to the pretest probability for acute coronary syndrome (group 1 with predominantly low-to-intermediate risk vs group 2 with high risk). A meta-regression analysis was also conducted using participant risk, type of SOC used, and the use or nonuse of high-sensitivity troponins as independent variables.

Results

The final analysis included 22 randomized controlled trials (9379 total participants; 4956 assigned to CCTA arms and 4423 to SOC arms). There was a 14% reduction in the length of stay and a 17% reduction in immediate costs for the CCTA arm compared with the SOC arm. In group 1, the length of stay was 17% shorter and costs were 21% lower using CCTA. There was no evidence of differences in referrals to invasive coronary angiography, myocardial infarction, mortality, rate of hospitalization, further stress testing, or readmissions between CCTA and SOC arms. There were more revascularizations (relative risk, 1.45) and medication changes (relative risk, 1.33) in participants with low-to-intermediate acute coronary syndrome risk and increased radiation exposure in high-risk participants (mean difference, 7.24 mSv) in the CCTA arm compared with the SOC arm. The meta-regression analysis found significant differences between CCTA and SOC arms for rate of hospitalization, further stress testing, and medication changes depending on the type of SOC (P < .05).

Conclusion

The results support the use of CCTA as a safe, rapid, and less expensive in the short term strategy to exclude acute coronary syndrome in low- to intermediate-risk patients presenting with acute chest pain.Keywords: Acute Coronary Syndrome, Chest Pain, Emergency Department, Coronary Computed Tomography, Usual Care Supplemental material is available for this article. Published under a CC BY 4.0 license.