Diagnostic Value of Comprehensive Cardiothoracic Dual Source CT for the Early Triage of Patients With Undifferentiated Acute Chest Pain (CAPTURE)
The purpose of this research is to determine the efficiency of a single dual source computed tomography (CT-DSCT) protocol to establish or exclude acute coronary syndrome (ACS), pulmonary embolism (PE) or aortic dissection (AD) as compared to the individual protocols. Endpoints aim to compare the rate of emergency department (ED) discharge, length of hospital stay, the diagnostic imaging test utilization, and the costs between the comprehensive and the standard protocol strategy in patients with undifferentiated chest discomfort or shortness of breath with a component of chest discomfort.
Acute Chest Pain
Radiation: Comprehensive Cardiothoracic DSCT arm
|Study Design:||Allocation: Randomized
Endpoint Classification: Safety/Efficacy Study
Intervention Model: Single Group Assignment
Masking: Open Label
Primary Purpose: Diagnostic
|Official Title:||Diagnostic Value of Comprehensive Cardiothoracic Dual Source CT for the Early Triage of Patients With Undifferentiated Acute Chest Pain|
- To compare rate of discharge and length of hospital stay between comprehensive cardiothoracic DSCT and dedicated PE/ACS/AD CT Scan protocols [ Time Frame: index hospitalization ] [ Designated as safety issue: Yes ]
- To compare the cost of care between the comprehensive cardiothoracic CT arm and the dedicated AD/ACS/PE CT protocol (standard of care) arm [ Time Frame: Index Hospitalization ] [ Designated as safety issue: No ]
|Study Start Date:||May 2008|
|Study Completion Date:||January 2010|
|Primary Completion Date:||June 2009 (Final data collection date for primary outcome measure)|
No Intervention: Dedicated CT arm
Subjects in this arm will continue to receive standard of care - that is the dedicated CT protocol to rule out either aortic dissection or acute coronary syndrome or pulmonary embolism.
Experimental: Comprehensive Cardiothoracic CT arm
Subjects in this arm receive a comprehensive cardiothoracic CT to evaluate the presence of acute coronary syndrome/aortic dissection/pulmonary embolism in a single scan.
Radiation: Comprehensive Cardiothoracic DSCT arm
Subjects in this arm will receive the comprehensive cardiothoracic DSCT to rule out aortic dissection/pulmonary embolism/acute coronary syndrome in a single scan.
Undifferentiated chest pain is one of the most common complaints in the acute care setting, accounting for over five million emergency department (ED) visits in the U.S. each year. Moreover, early and accurate triage of these patients remains difficult as neither the chest pain history, a single set of biochemical markers for myocardial necrosis, or the initial 12-lead electrocardiogram (ECG), alone or in combination, identify a group of patients that can be safely discharged without further diagnostic testing. As a result, patients presenting to the ED with undifferentiated chest pain are often evaluated with multiple examinations to exclude the presence of myocardial infarction (MI),pulmonary embolism (PE), and/or aortic dissection (AD).
While contrast-enhanced spiral computed tomography angiography (CTA) has become a standard procedure in the evaluation of the presence of PE and AD, it was only within the past few years that noninvasive detection of coronary artery stenosis with CTA has become feasible. Coronary CTA has been proven to be an effective tool to rule out CAD with reported sensitivities of 93-99% and specificities of 95-97% as compared to invasive coronary angiography.
Recent data from our ROMICAT (Rule Out Myocardial Infarction by Computer Assisted Tomography) study indicates that coronary CTA accurately rules out acute coronary syndrome (ACS) in patients with acute chest pain and therefore may enhance the diagnostic work up of chest pain patients in the ED. Moreover, this study demonstrated the distribution of several CT-angiographic patterns of CAD which may change management of subjects with inconclusive initial ED evaluation admitted to the hospital. For example, CTA demonstrated the absence of any CAD in 50% of the patients. None of the subjects without any CAD on CTA developed unstable angina or had an MI during index hospitalization. Furthermore, none of these patients had any MACE over the next six months, confirming previous observations in ACS patients. These data suggest that 50% of hospital admissions could be saved. Another recent study our group has demonstrated that an individually tailored ECG-gated CT protocol with a single contrast injection permits simultaneous visualization of the coronary arteries, thoracic aorta, and pulmonary arteries with excellent image quality.
The very recent introduction of dual source CT (DSCT) technology offers a two-fold improvement in temporal resolution as compared to the standard 64-slice CTA that was used for these studies (83ms vs. 165ms, respectively). This significant improvement in temporal resolution allows for the acquisition of diagnostic images with higher and irregular heart rates, precluding the need for intravenous beta blockade. Given the improved temporal resolution and faster acquisition time, the amount of radiation exposure can be markedly reduced in many patients.
With the need to improve triage of patients with undifferentiated chest pain and the advantages offered by DSCT technology, several observational case series have suggested the feasibility of a comprehensive thoracic DSCT (CT-DSCT) to simultaneously evaluate the coronary arteries, thoracic aorta, and pulmonary arteries. Whether this will result in an improvement of patient management and test utilization remains unclear as compared to a standard ED evaluation protocol needs to be evaluated.
Thus, the purpose of this research is to determine the efficiency of a single CT-DSCT protocol to establish or exclude MI, PE, or AD as compared to the individual protocols. Endpoints aim to compare the rate of ED discharge, length of hospital stay, the diagnostic imaging test utilization, and the costs between the comprehensive and the standard protocol strategy in patients with undifferentiated chest discomfort or shortness of breath with a component of chest discomfort.
|United States, Massachusetts|
|Massachusetts General Hospital|
|Boston, Massachusetts, United States, 02114|
|Principal Investigator:||Udo Hoffmann, MD, MPH||Massachusetts General Hospital|