RSNA: Using CT in the ED for acute chest pain requires a strategic plan
CHICAGO—There are pros and cons to beginning a CT emergency department (ED) program for the evaluation of patients with acute chest pain; however, the undertaking requires asking some strategic questions to establish a clear-cut protocol, according to a Nov. 28 presentation by Harold I. Litt, MD, PhD, chief of cardiovascular imaging at Penn Medicine in Philadelphia, at the 97th Scientific Assembly and Annual Meeting of the Radiological Society of North America (RSNA).

Ten million chest pain patients present to the ED annually in U.S., and approximately 85 to 95 percent have acute chest pain. “However, evaluation of acute chest pain is a very inefficient use of healthcare resources, given that the majority of patients will not have the disease that you are trying to exclude,” Litt said. 

“It’s very important to know what the customers want,” he noted. “Radiologists need to understand that the goals and desires of the cardiologists and emergency room physicians are very different in assessing patients with acute chest pain.”

The cardiologist wants to know whether the patient is experiencing an acute coronary syndrome, the patient’s short-term morbidity rate, if there is a need for intervention and can he or she provide long-term risk assessment. Conversely, the ED physician wants to know how long the patient will be staying in the ED, will an event occur if the patient is sent home and should the patient be referred to another department. “If radiologists understand these very mindsets, they can best serve these specialties,” Litt said. 

Some positive data about CT, according to Litt, is that:
  • CT is safe with a less than 1 percent 30-day event rate;
  • CT costs less with a $250 to $2,500 savings per patient than nuclear testing;
  • Most payors cover the modality for this application;
  • CT reduces repeat ED visits and readmissions;
  • CT provides a good warranty period for negative evaluation; and
  • CT provides risk assessment for outpatient treatment. 

However, it is important that EDs perform the exams as efficiently and cheaply as possible, Litt noted.

The disadvantages of CT are:
  • Radiation dose levels (about 10 mSv is U.S. average);
  • About 15 percent of patients cannot undergo CT, even if the scan is indicated;
  • Potential for incidental findings; and
  • Low positive predictive value.

Because of the pros and cons, providers need to make up-front decisions when implementing a strategic CT in the ED program. First, Litt said the department should consider what type of patients they want to study—where in the risk profile they want to screen with CT.

Then, they need to consider what type of ED staff will be required for the program and how many hours they plan to use the CT for this purpose. He said that ED staff is most important because they decide who will undergo these procedures. Secondarily, they need to consider the staff required for those who will read the CT exams, especially if it is a 24-hour program—someone to administer medications prior to the scan, technologists to perform the scan as well as a supervising radiologist or cardiologist to read the scan. 

Finally, Litt recommended that current technology, such as higher slice CTs, truly benefits the provider that undertakes this type of program.

The success of the program will depend on the strategic approach of the provider, Litt summed.