Coronary CTA

[roja]

So, just got out of a faculty meeting where radiology/cards presented a new ED protocol wanting to use this tool.

I, personally, have several issues regarding this.

The presenter put up several studies, all with NPV of 98% or so. However, the Hollander article, as well as the others, used 'low risk patients' where TIMI's ranged from 0-3 to get this NPV. My issue was, if you look at the studies, a HUGE number of those patients were in the TIMI 0 score. In essence, patients that don't fall within the proposed protocol.

My issue is that this NPV can't be cross applied to the higher TIMI's (ie intermediate risk patients) as it is 1-an inaccurate NPV and 2- is not standard of care.

I know data is going to be gathered and this seems like murky water to me. No one proposes telling the patients that the use of CCTA is untested as a screening tool in intermediates.... and if we do tell them and gather data, this seems to fall under research, with all the IRB issues that surround it.

In addition to this, CCTA requires that Bblockers be given to slow the heart rate (now with rising evidence to support NOT giving Bblockers in this patient population).

Anyone using this? Have better data than what was presented to me?

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[BADMD]

So, just got out of a faculty meeting where radiology/cards presented a new ED protocol wanting to use this tool.

There is more data to support using CTA. I don't have it in hand at this moment unfortunately.

Our ED group recently decided to create our own protocol. The taskforce group came up with a similar proposal, actually. One of the other attendings, who is more familiar with the literature, is pulling the relevant articles. Apparently one of the articles out there showed that those with positive CTAs had a much higher intervention rate on cardiac cath than those with positive stress tests. The in ED time was much less for CTA.

These are two of the paper's he mentioned:
http://www.ncbi.nlm.nih.gov/pubmed/...nel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
http://www.ncbi.nlm.nih.gov/pubmed/...nel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

These two studies may have used the same data set. I'll have to ask them.

The problem of Hollander's population did come up and was acknowledged. I still see the protocol as very viable and I'm willing to go with it.

As for the betablocker issue, I think that is a one off problem. The problem is for those who are having myocardial damage. As much as we use TIMI risk stratification, realistically, there are only 5, not 7 points available, as most ED docs won't risk stratify a patient with ST depression and chest pain or positive enzymes. The risk of a patient going into shock from a betablocker is going to be much lower in a someone with a TIMI risk score <3 than one who looks like they are having a STEMI or an even an NSTEMI. Obviously not all patients low risk CP are going to tolerate the big dose of betablockers, but I'm not as worried about this group as I am about the STEMI group.

 

[Jeff698]

I'm worried about this test as well.

The first issue is obviously the radiation dose. I understand it can be less than an angiogram but if the test is positive, they get that plus the angio dose when the stent goes in.

Any test, if used in a low risk population as Roja suggests, is likely going to have more false positives necessitating more interventions than true positives. If we see this test as an easy answer for our low risk patients, we're going to cause more problems than we solve.

Needless to say, I'm a bit skeptical at present.

Take care,
Jeff