Safety of early emergency department discharge utilising a novel 320-slice coronary computed tomographic angiography guided algorithm including discharge after a single troponin: A new paradigm in chest pain assessment

  • Dr Arthur Nasis, Monash Cardiovascular Research Centre, MonashHEART, Southern Health and Monash University Department of Medicine (MMC), Australia
  • Prof Ian Meredith, Medical Vice President, Heart Foundation, Victoria - Scientific Committee Chair, Australia
  • Prof James Cameron, Monash Cardiovascular Research Centre, MonashHEART, Southern Health and Monash University Department of Medicine (MMC), Australia
  • Dr Paul Antonis, Monash Cardiovascular Research Centre, MonashHEART, Southern Health and Monash University Department of Medicine (MMC), Australia
  • Dr Philip Mottram, Monash Cardiovascular Research Centre, MonashHEART, Southern Health and Monash University Department of Medicine (MMC), Australia
  • Dr John Troupis, Department of Diagnostic Imaging, Southern Health, Australia
  • Prof George Braitberg, Department of Emergency Medicine, Southern Health, Australia
  • Dr Sujith Seneviratne, Monash Cardiovascular Research Centre, MonashHEART, Southern Health and Monash University Department of Medicine (MMC), Australia

Objective: To determine the safety and impact on length of stay (LOS) of a coronary computed tomographic angiography (CCTA)-guided algorithm for triaging chest pain patients, including discharge following a single negative troponin.
Methods: 203 consecutive patients (age 55 ±11 years, 60% male) with low-to-intermediate risk (TIMI 0-4) ischaemic-type chest pain were prospectively evaluated using 320-slice CCTA after presenting to the Emergency Department (ED) with normal troponin and electrocardiogram. Patients without overt plaque on CCTA were discharged after a single troponin (Group 1). Patients with mild (<50%) stenoses were discharged after negative 6-hour troponin, as were patients with moderate (50-70%) stenoses with additional outpatient stress echocardiography (Group 2). Patients with severe (>70%) stenoses were admitted. LOS was also compared to a retrospective cohort of 102 consecutive low-to-intermediate risk patients who presented to the ED with chest pain immediately prior to the CCTA-guided algorithm being implemented who underwent traditional standard-of-care workup without CCTA (Group 3).
Results: Group 1 comprised 32% (65 patients) and group 2 comprised 53% (107 patients) of patients who underwent CCTA-guided investigation, with 15% (31 patients) having severe (>70%) stenoses on CCTA and admitted to hospital. At mean 14.2-month follow-up (range 5.5-24.7 months), there were no deaths, myocardial infarctions or chest pain readmissions (95%CI 0-1.85%) in patients discharged from ED. Mean LOS for Groups 1, 2 and 3 was 397±23, 549±18 and 697±28 minutes, respectively (p<0.01).
Conclusions: Triaging low-to-intermediate risk chest pain patients with CCTA allows early and safe ED discharge with no clinical sequelae at medium-term follow-up.