Diagnostic strategies in acute chest pain: evaluating the role of coronary computed tomography angiography

Patients presenting to the emergency department (ED) with acute chest pain but without ischemic ST changes on ECG or elevated troponin levels pose a diagnostic challenge. Current guidelines recommend non-invasive evaluations, such as coronary computed tomography angiography (CCTA), to exclude coronary artery disease (CAD) or guide further management. However, CCTA remains underutilized, with many patients either discharged for outpatient follow-up or admitted for invasive coronary angiography (ICA), even when immediate invasive assessment may not be necessary.

This study aimed to evaluate management strategies and healthcare costs for patients with acute chest pain, no ST-segment elevation, and normal troponin levels, focusing on comparing invasive and non-invasive CCTA approaches in both hospitalized and discharged patients.

We conducted a retrospective analysis of patients presenting with acute chest pain, no ST-segment elevation, and normal troponin levels, who were either hospitalized or discharged from the ED between January and June 2024. Data collected included the initial diagnostic approach (ICA or non-invasive testing), findings, and subsequent management, whether medical or requiring revascularization. For revascularization cases, the type of intervention (percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG)) was noted. Additionally, data on length of stay and healthcare costs were recorded for hospitalized patients.

A total of 173 patients were analyzed, with 108 discharged and 65 hospitalized. In the discharged group, all patients underwent CCTA as recommended. Among these, 30 (30.6%) showed no evidence of CAD, 53 (49.1%) were diagnosed with non-obstructive CAD and managed medically, and 22 (20.4%) had suspected obstructive CAD, leading to invasive evaluation. Of those referred, 13 (12.0%) underwent PCI, and 1 (0.9%) received CABG. In the hospitalized group, 53 (81.5%) underwent ICA, with only 8 (12.3%) requiring PCI; no CABG was performed. Among the 12 (18.5%) who received non-invasive testing, CCTA was used in 5 (7.7%), identifying CAD in 1 patient who was managed medically. Average costs and lengths of stay were significantly lower for non-invasive testing, averaging €657 and 3.1 days, compared to €2876 and 4.0 days for ICA without PCI and €4259 for those with PCI.

These findings indicate that among patients with acute chest pain, normal troponin levels, and no ST-segment elevation, only one in eight requires revascularization, regardless of inpatient or outpatient status. CCTA is as effective as invasive coronary angiography in identifying cases needing intervention but is significantly more cost-effective. These results support the use of CCTA in the ED to improve management and reduce costs.