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CT
Heart Scan in ER Saves Time and Money
Randomized Trial Against Current "Standard of Care" Shows Safety and Benefits |
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February 28, 2007 -- You feel chest pains and are afraid you may be having a heart problem. You go to the Emergency Room. You are not alone. You are one of six million Americans who visit the ER annually because of chest pain. In the ER, an EKG and an enzyme level test are performed to tell if you are having a heart attack. It turns out you're aren't. But if you aren't having a heart attack, are you on the road to one? Do these chest pains mean you have blockages in your coronary arteries? 50% of the time the answer is no -- the source of the pain is non-cardiac. This diagnosis is arrived at using the current "Standard of Care" (SOC) often involving a stress test. Time from arrival at the ER to diagnosis: 15 hours. In this week's Journal of the American College of Cardiology, a study compares this standard diagnostic pathway to a new one which utilizes 64-slice CT scanning to determine whether or not the chest pains are cardiac-related. Multislice CT scanning can quickly image the heart and its arteries non-invasively. A growing number of studies have shown that CT has high precision in excluding the presence of arterial blockages. In the JACC study, almost 200 patients were randomized to either nuclear stress testing or multislice CT at William Beaumont Hospital in Royal Oak, Michigan. The results showed no difference in the outcomes of the two groups, but there was a great difference in the time spent before a diagnosis was made. The 15 hours for standard care (stress testing) was reduced to less than 4 with CT scanning. This also translated to lower costs and less patients having to stay in hospital. An additional benefit, one not discussed in the study report, is that stress testing has been shown to be somewhat less reliable in women; women get a higher degree of false positives. A woman with chest pain may get a positive stress test which then sends her to the cath lab to get an invasive angiogram -- only to find no disease at all. This adds significant expense, time and the chance for complications. The multislice CT angiogram can help avoid this situation. The authors had a few caveats. Patients with intermediate blockages (26-70%) on CT scanning needed to get a nuclear stress test to confirm whether the blockage was the cause of the chest pain. 25% of the patients fell into this intermediate group and, upon further testing, most of these patients were found free of significant disease. Also some scans were not of high enough quality to make a determination. There are also concerns over multiple testing and the total radiation dose. But 75% of all patients scanned via CT were judged as normal and could immediately and safely be discharged with no further testing. The JACC study mirrors another one done in a Pennsylvania hospital that Angioplasty.Org reported on earlier this month. The Pennsylvania study showed similar results. Cardiac CT, as it advances technically, as more physicians are trained in its use, and as it becomes more readily available, has the potential to significantly change the diagnostic pathway for coronary artery disease.
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