RANT: CTA? Not in the ED!

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No me gusta!

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Nilesh P. -

HI Mel, Valerie:

Nice rant on CT coronaries and I do agree at this point in time. What are your thoughts on the use of Calcium scoring in the ED in low risk chest pain patients? It may obviate need for admission if calcium score zero or low. Some data to show it is independent predictor of risk. Downsides are it is low dose radiation, time to do, and false positives. Nilesh

Valerie C. N. -

Hi, Nilesh. I feel the same about calcium scoring as I do about CCTAs in general. If it's a low-risk patient I plan to send home, which is well-supported by the current guidelines and a host of good studies, then I don't want to know their calcium score. As you say, I also don't want to spend the time and radiation required to get that score. You mention obviating the need for admission, but these are patients that are already safe for us to send home--with no ischemic findings on EKG and 2 negative troponins. Perhaps there is a place for CCTA in the moderate to high-risk patient with an abnormal EKG but atypical pain and negative troponins--this is a different kettle of fish. I don't think we have sorted out that kettle yet, but I'll be eagerly awaiting more studies on the topic. --Val

Nilesh P. -

Hi Valerie,

Thanks for your feedback. We are playing around with calcium scoring at our place and developing a low risk chest pain protocol so it is good to hear your take on this.


Jeffrey A. -

THANK YOU! Finally a voice of reason. We have somehow taken on the role of thinking we have to be the definitive experts on all diseases. NOT TRUE. We need to decide sick vs not sick; admit vs dc. We need to know when to refer to appropriate specialists. We DO NOT need to rule out every disease on every patient to be good physicians. This is part of why we have been successful but it is also why most of our ED's are now drowning. Thank you trying to keep the ED the ED.

Valerie C. N. -

Hi, Jeffrey, you're welcome! I'm glad you agree. --Val

Brian D. -

Bravo Val! Well put...

Only thing to also consider are the harms caused by "false positives." I.e. those that have incidental findings that have nothing to do with their chest pain presentation. The Litt paper showed a tripping of the diagnosis of CAD. Given the prevalence in the community, many of these had to be false positive...

Salim R. -

Agree with this rant, but what if you have an indigent population that you cant get follow up for at 72 hrs? Are we still responsible for doing the CCTA or stress test? Sorry to be devils advocate....

Valerie C. N. -

Hi, Salim, of course you have to do what you have to do; having an indigent population is always tough. At my shop in inner city San Diego, we have about 25% unfunded patients and another 25% who have Medicaid only, and we have worked out a deal with the cardiologists that they will see any of these patients in their office either for free or for a nominal fee within 72 hours if they meet all the low-risk criteria. Our care and their care is basically pro bono, but we all figure it's better than a hospital admission. They will usually do the stress test right there in their office.
I have the good fortune to work at a Catholic hospital where charity care is the norm and everyone believes in "the mission," but I've seen this kind of arrangement work at other types of hospitals as well. Good luck!

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