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CT Angiography For Low Risk Chest Pain.

Judd Hollander, MD, Mel Herbert, MD MBBS FAAEM, David Newman, MD, Al Sacchetti, MD, and Amal Mattu, MD FAAEM
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C3 Project Written Summary:Vaginal Bleeding, Pediatric Traumatic Musculoskeletal Disorders 2 MB - PDF

The Australian wonderkid talks with Judd about his NEJM paper about using CT Angiography to rule out the badness that could be lurking in patients with chest pain. Tack on some critical analysis by David and a responses from Amal and Al and you have one kick $#% segment.

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Derek I., M.D. -

I think that there is no doubt that CT angiography is equivalent or better to stress testing for low risk chest pain. I also believe that it gets patients out of the hospital earlier. However I think we are asking the wrong question here. Are we doing any benefit for patients? I think clearly the answer is no since all of these patients did well anyway whether we get the test or not. We should not subject patients to unnecessary tests for our insecurity About getting sued. Instead of these tests being done in the emergency department, they could be done on an outpatient setting. And these patients do not have follow-up to get the outpatient test, they will not have a follow-up in case of a positive test anyway

brendanC -

low risk chest pain should get a r/o and be d/c'd. Unstable angina patients should be considered for a CTA to help prevent a cath and an admit. That is where we should START with CTA.
How do we get the radiologist to do it? If insurance won't pay for it, our docs won't do it. Any suggestions?

Mike J., M.D. -

Really? CTCA for low risk CP? What about the real world, where I work? I can do a two enzyme rule out in 3 hrs. I can't wait 5hrs for a ct, an hour for post processing and result in my 8 bed (7 are monitored) which sees 70 pts/day. In addition, I don't have a 64 slice scanner with ability to do gated images, nor will I in the next 5 years.

WHat is a 2 troponin rule out anyway? 2hrs, 6hrs, 9hrs? Which one gets us to the magic 1% risk? How does it apply to the 54 y.o. female who had 20+ hrs of cp, w/ nausea, sob radiating to her arm with normal ECGs and enzymes? (She's at home, doing well).

What we need is better clinical assessment, not more toys.

Sean G., M.D. -

agree with Mike J above. I am sick of adding more and more expense to these low risk cp R/O's. I have been sending these home for 15 years with gestalt, trops and serial ekg's and haven't been sued yet. At some point we have to acknowledge that there is not a limitless fund of healthcare dollars. If we follow AHA guidelines in our ER's America will be a Stephen King post apocalyptic wasteland in 5 years.

joanna M. -

maybe its a canada thing but my experience (rural and community hospitals) but we do seem to be sending low risk r/o home with outpatient stress tests right now. Not sure what doing ct angio adds to this evaluation as it is invasive and does not give a functional assessment. I know stress tests are essentially useless as a roughly 70% sensitive test with a low pre test prob but the argument was not that ct is any better, and if any lesion is seen theres only 50% chance it would correlate to symptoms anyways, no? stress test before cath would still be recommended I think? just a thought from the moose-ridden great white rural north...

Patrick D. -

The culture is already changing, our hospitalists now routinely question why we didn't get a CCTA on the 65M c HTN, HLD, DM with 2 hrs substernal pressure c n/v and diaphoresis. These patients are too high risk to have a CCTA and need to be evaluated by a cardiologist rather than receive a CCTA that may show 40% stenosis of the LAD, in which case is still technically negative...

The CCTA is complicating an already extremely complicated area in emergency medicine and our hospitalists are already adopting it as an inappropriate standard.

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Episode 130 Full episode audio for MD edition 238:19 min - 100 MB - M4AEM:RAP July 2012 Written Summmary 1 MB - PDFC3 Project Written Summary:Vaginal Bleeding, Pediatric Traumatic Musculoskeletal Disorders 2 MB - PDF