Can Lower-Risk Patients with Negative CCTA Be Safely Discharged from the Emergency Department?

No patients with <50% stenosis experienced cardiac death or myocardial infarction within 30 days.


Coronary computed tomographic angiography (CCTA) has a high negative predictive value for excluding coronary artery disease (CAD). Researchers have now assessed CCTA's value as an initial test for low-to-intermediate–risk patients (Thrombosis in Myocardial Infarction score, 0–2) without renal insufficiency who presented with chest pain to one of five emergency departments (EDs). Participants, all of whom warranted admission or further testing to rule out CAD, were randomized to CCTA (908 patients) or traditional care (462 patients).

Of the patients assigned to CCTA, 16% did not undergo it, most often because of persistently high heart rate; of the 767 who did, 83% had no significant CAD (defined as <50% stenosis). In the traditional-care group, 295 patients (64%) underwent diagnostic testing, most often stress imaging.

In each of the original randomized groups, there were no cardiac deaths, one bradyarrhythmia (thought to be treatment-related), and a 1% rate of myocardial infarction (MI). None of the patients with negative CCTA experienced the primary endpoint: cardiac death or MI within 30 days. Compared with the traditional-care group, the CCTA group had a significantly higher rate of discharge from the ED (49.6% vs. 22.7%), a significantly shorter median length of stay (18 vs. 25 hours), and a higher rate of CAD detection (9.0% vs. 3.5%). The two groups had similar rates of catheterization and other follow-up testing within 30 days.

Citation(s):

Litt HI et al. CT angiography for safe discharge of patients with possible acute coronary syndromes. N Engl J Med 2012 Mar 26; [e-pub ahead of print].