Is coronary CTA or stress echocardiography better for chest pain triage?

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Coronary computed tomography angiography (CTA) is the current go-to for triaging chest pain patients in the emergency department (ED), but a recent study found the often-overlooked stress echocardiography (SE) may actually be safer and provide patients with a better overall experience.In the study, published online June 13 in the Journal of the American College of Cardiology: Cardiovascular Imaging, authors cited concerns with CTA related to radiation exposure, increased downstream resource use, and incidental findings complications despite its rapid increased use in the ED.

            A team of New York researchers randomized 400 low-to intermediate-risk ED acute chest pain patients with no known history of coronary artery disease and a negative initial serum troponin level to immediate coronary CTA or SE.“In our busy urban ED setting, SE was safe and effective in chest pain triage compared with coronary CTA,” wrote corresponding author Jeffrey M. Levsky, MD, PhD with Montefiore Medical Center and Albert Einstein College of Medicine’s radiology department in New York, and colleagues. “SE resulted in the discharge of a significantly higher proportion of patients with significantly shorter lengths of stay, was safe at intermediate-term follow-up, and provided a better patient experience.”
 
             Thirty-nine coronary CTA patients and 22 SE patients were hospitalized with a median ED length of stay for discharged patients of 5.4 hours for CTA and 4.7 hours for SE.The median hospital length of stay was 58 hours for coronary CTA compared to 34 hours for SE patients. Additionally, over a median 24 months follow-up, stress echocardiography patients had fewer adverse cardiovascular events (11), compared to those who underwent CTA (seven events).

              Authors noted their findings stray from previous randomized trials which showed a decreased length of stay with coronary CTA compared to standard care.The patient population was relatively low-risk, and authors maintained more work is needed to better understand the appropriate imaging approach for different situations. In an accompanying editorial, a pair of authors shared the same sentiment.