• Edward Hulten, Christopher Pickett, Marcio Sommer Bittencourt, Todd C Villines, Sara Petrillo, Marcelo F Di Carli, and Ron Blankstein.
• Noninvasive Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts 02115, USA. ehulten@partners.org
• J. Am. Coll. Cardiol. 2013 Feb 26;61(8):880-92.

ObjectivesThe aim of the study was to systematically review and perform a meta-analysis of randomized, controlled trials of coronary computed tomography angiography (CCTA) versus usual care (UC) triage of acute chest pain in the emergency department (ED).BackgroundCCTA allows rapid evaluation of patients presenting to the ED with acute chest pain syndromes; however, the impact of such testing on patient management and downstream testing has emerged as a concern.MethodsWe systematically searched for randomized, controlled trials of CCTA in the ED and performed a meta-analysis of clinical outcomes.ResultsFour randomized, controlled trials were included, with 1,869 patients undergoing CCTA and 1,397 undergoing UC. There were no deaths and no difference in the incidence of myocardial infarction, post-discharge ED visits, or rehospitalizations. Four studies reported decreased length of stay with CCTA and 3 reported cost savings; 8.4% of patients undergoing CCTA versus 6.3% of those receiving UC underwent invasive coronary angiography (ICA), whereas 4.6% of patients undergoing CCTA versus 2.6% of those receiving UC underwent coronary revascularization. The odds ratio of ICA for CCTA patients versus UC patients was 1.36 (95% confidence interval [CI]: 1.03 to 1.80, p = 0.030), and for revascularization, it was 1.81 (95% CI: 1.20 to 2.72, p = 0.004). The absolute increase in ICA after CCTA was 21 per 1,000 CCTA patients (95% CI: 1.8 to 44.9), and the number needed to scan was 48. The absolute increase in revascularization after CCTA was 20 per 1,000 patients (95% CI: 5.0 to 41.4); the number needed to scan was 50. Both percutaneous coronary intervention and coronary artery bypass graft surgery independently contributed to the significant increase in revascularization.ConclusionsCompared with UC, the use of CCTA in the ED is associated with decreased ED cost and length of stay but increased ICA and revascularization.Copyright © 2013 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

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