Skip to main content
SpringerLink
Log in

Strategy for Building a Successful Coronary CT Angiography Program in the Emergency Department

  • Cardiac Computed Tomography (TC Villines, Section Editor)
  • Published:
Current Cardiovascular Imaging Reports Aims and scope Submit manuscript

Abstract

Coronary CT angiography (cCTA) is a rapid, accurate, safe, and efficient technique for evaluating acute chest pain in patients with low-intermediate pretest probability of coronary artery disease. In this review, we outline a strategy for building and maintaining a successful cCTA program in the emergency department. We define success as the ability for a program to improve patient outcomes and yield cost savings for a health care organization. Establishing a successful program can be achieved by organizing a multidisciplinary task force, developing a shared vision, utilizing established guidelines, developing standardized workflow and chest pain management pathways, launching an effective educational campaign, and implementing a quality assurance program.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Bayley MD, Schwartz JS, Shofer FS, et al. The financial burden of emergency department congestion and hospital crowding for chest pain patients awaiting admission. Ann Emerg Med. 2005;45:110–7.

    Article  PubMed  Google Scholar 

  2. Schull MJ, Vermeulen M, Slaughter G, Morrison L, Daly P. Emergency department crowding and thrombolysis delays in acute myocardial infarction. Ann Emerg Med. 2004;44:577–85.

    Article  PubMed  Google Scholar 

  3. Samad Z, Hakeem A, Mahmood SS, et al. A meta-analysis and systematic review of computed tomography angiography as a diagnostic triage tool for patients with chest pain presenting to the emergency department. J Nucl Cardiol Off Publ Am Soc Nucl Cardiol. 2012;19:364–76.

    Article  Google Scholar 

  4. Litt HI, Gatsonis C, Snyder B, et al. CT angiography for safe discharge of patients with possible acute coronary syndromes. N Engl J Med. 2012;366:1393–403.

    Article  CAS  PubMed  Google Scholar 

  5. Goldstein JA, Chinnaiyan KM, Abidov A, et al. The CT-STAT (Coronary Computed Tomographic Angiography for Systematic Triage of Acute Chest Pain Patients to Treatment) trial. J Am Coll Cardiol. 2011;58:1414–22.

    Article  PubMed  Google Scholar 

  6. Hoffmann U, Truong QA, Schoenfeld DA, et al. Coronary CT angiography versus standard evaluation in acute chest pain. N Engl J Med. 2012;367:299–308.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  7. Truong QA, Hayden D, Woodard PK, et al. Sex differences in the effectiveness of early coronary computed tomographic angiography compared with standard emergency department evaluation for acute chest pain: the rule-out myocardial infarction with Computer-Assisted Tomography (ROMICAT)-II Trial. Circulation. 2013;127:2494–502.

    Article  PubMed Central  PubMed  Google Scholar 

  8. Hulten E, Pickett C, Bittencourt MS, et al. Outcomes after coronary computed tomography angiography in the emergency department: a systematic review and meta-analysis of randomized, controlled trials. J Am Coll Cardiol. 2013;61:880–92. An in-depth and well-organized meta-analysis and systematic review of randomized, controlled trials of cCTA versus usual care for evaluation of acute chest pain in the ED, this paper nicely summarizes the benefits and limitations of a cCTA-based approach.

    Article  PubMed  Google Scholar 

  9. Cury RC, Feuchtner GM, Batlle JC, et al. Triage of patients presenting with chest pain to the emergency department: implementation of coronary CT angiography in a large urban health care system. AJR Am J Roentgenol. 2013;200:57–65.

    Article  PubMed  Google Scholar 

  10. Nasis A, Meredith IT, Sud PS, Cameron JD, Troupis JM, Seneviratne SK. Long-term outcome after CT angiography in patients with possible acute coronary syndrome. Radiology. 2014;272:674–82.

    Article  PubMed  Google Scholar 

  11. Schlett CL, Banerji D, Siegel E, et al. Prognostic value of CT angiography for major adverse cardiac events in patients with acute chest pain from the emergency department: 2-year outcomes of the ROMICAT trial. JACC. Cardiovasc Imaging. 2011;4:481–91. This article investigated the 2-year prognostic value of cCTA for predicting major adverse cardiac events among 368 patients from the ROMICAT trial who presented to the ED with acute chest pain. Investigators found the absence of coronary artery disease on cCTA provided a 2-year event-free warranty period.

    Article  Google Scholar 

  12. Hollander JE, Chang AM, Shofer FS, et al. One-year outcomes following coronary computerized tomographic angiography for evaluation of emergency department patients with potential acute coronary syndrome. Acad Emerg Med Off J Soc Acad Emerg Med. 2009;16:693–8.

    Article  Google Scholar 

  13. Hamilton-Craig C, Fifoot A, Hansen M, et al. Diagnostic performance and cost of CT angiography versus stress ECG--a randomized prospective study of suspected acute coronary syndrome chest pain in the emergency department (CT-COMPARE). Int J Cardiol. 2014;177:867–73. CT-COMPARE is the first randomized trial directly comparing cCTA to exercise stress ECG for the evaluation of low-intermediate risk acute chest pain. The authors report improved diagnostic performance with a cCTA-based approach, combined with reduced length-of-stay and lower hospital costs.

    Article  PubMed  Google Scholar 

  14. Maroules CD, Blaha MJ, El-Haddad MA, Ferencik M, Cury RC. Establishing a successful coronary CT angiography program in the emergency department: official writing of the Fellow and Resident Leaders of the Society of Cardiovascular Computed Tomography (FiRST). J Cardiovasc Comput Tomogr. 2013;7:150–6.

    Article  PubMed  Google Scholar 

  15. Budoff MJ, Achenbach S, Berman DS, et al. Task force 13: training in advanced cardiovascular imaging (computed tomography). J Cardiovasc Comput Tomogr. 2008;2:130–5.

    Article  PubMed  Google Scholar 

  16. Raff GL, Chinnaiyan KM, Cury RC, et al. SCCT guidelines on the use of coronary computed tomographic angiography for patients presenting with acute chest pain to the emergency department: a report of the Society of Cardiovascular Computed Tomography Guidelines Committee. J Cardiovasc Comput Tomogr. 2014;8:254–71. The article features guidelines from the Society of Cardiovascular Computed Tomography (SCCT) for performance of cCTA in the emergency department for evaluation of acute chest pain. These guidelines serve as an important educational tool for physicians to standardize cCTA in the ED for improving patient care based on broad expert consensus and available data.

    Article  PubMed  Google Scholar 

  17. Hulten E, Goehler A, Bittencourt MS, et al. Cost and resource utilization associated with use of computed tomography to evaluate chest pain in the emergency department: the rule out myocardial infarction using computer assisted tomography (ROMICAT) study. Circ Cardiovasc Qual Outcomes. 2013;6:514–24.

    Article  PubMed Central  PubMed  Google Scholar 

  18. Cheezum MK, Blankstein R. Coronary computed tomographic angiography: its role in emergency department triage. Circulation. 2014;130:2052–6.

    Article  PubMed  Google Scholar 

  19. Abbara S, Arbab-Zadeh A, Callister TQ, et al. SCCT guidelines for performance of coronary computed tomographic angiography: a report of the Society of Cardiovascular Computed Tomography Guidelines Committee. J Cardiovasc Comput Tomogr. 2009;3:190–204.

    Article  PubMed  Google Scholar 

  20. Leipsic J, Abbara S, Achenbach S, et al. SCCT guidelines for the interpretation and reporting of coronary CT angiography: a report of the Society of Cardiovascular Computed Tomography Guidelines Committee. J Cardiovasc Comput Tomogr. 2014;8:342–58.

    Article  PubMed  Google Scholar 

  21. Halliburton SS, Abbara S, Chen MY, et al. SCCT guidelines on radiation dose and dose-optimization strategies in cardiovascular CT. J Cardiovasc Comput Tomogr. 2011;5:198–224.

    Article  PubMed Central  PubMed  Google Scholar 

  22. Pannu HK, Alvarez Jr W, Fishman EK. Beta-blockers for cardiac CT: a primer for the radiologist. AJR Am J Roentgenol. 2006;186:S341–5.

    Article  PubMed  Google Scholar 

  23. Cury RC, Feuchtner G, Mascioli C, et al. Cardiac CT in the emergency department: convincing evidence, but cautious implementation. J Nucl Cardiol Off Publ Am Soc Nucl Cardiol. 2011;18:331–41.

    Article  Google Scholar 

  24. Taylor AJ, Cerqueira M, Hodgson JM, et al. ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR 2010 appropriate use criteria for cardiac computed tomography. A report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the North American Society for Cardiovascular Imaging, the Society for Cardiovascular Angiography and Interventions, and the Society for Cardiovascular Magnetic Resonance. J Am Coll Cardiol. 2010;56:1864–94.

    Article  PubMed  Google Scholar 

  25. Cheezum MK, Bittencourt MS, Hulten EA, Scirica BM, Villines TC, Blankstein R. Coronary computed tomographic angiography in the emergency room: state of the art. Expert Rev Cardiovasc Ther. 2014;12:241–53.

    Article  CAS  PubMed  Google Scholar 

  26. Bezerra HG, Loureiro R, Irlbeck T, et al. Incremental value of myocardial perfusion over regional left ventricular function and coronary stenosis by cardiac CT for the detection of acute coronary syndromes in high-risk patients: a subgroup analysis of the ROMICAT trial. J Cardiovasc Comput Tomogr. 2011;5:382–91.

    Article  PubMed  Google Scholar 

  27. Branch KR, Busey J, Mitsumori LM, et al. Diagnostic performance of resting CT myocardial perfusion in patients with possible acute coronary syndrome. AJR Am J Roentgenol. 2013;200:W450–7.

    Article  PubMed Central  PubMed  Google Scholar 

  28. Pursnani A, Lee AM, Mayrhofer T, et al. Early resting myocardial computed tomography perfusion for the detection of acute coronary syndrome in patients with coronary artery disease. Circ Cardiovasc Imaging. 2015;8:e002404.

    Article  PubMed  Google Scholar 

  29. Lin FY, Dunning AM, Narula J, et al. Impact of an automated multimodality point-of-order decision support tool on rates of appropriate testing and clinical decision making for individuals with suspected coronary artery disease: a prospective multicenter study. J Am Coll Cardiol. 2013;62:308–16.

    Article  PubMed  Google Scholar 

  30. Staniak HL, Bittencourt MS, Pickett C, et al. Coronary CT angiography for acute chest pain in the emergency department. J Cardiovasc Comput Tomogr. 2014;8:359–67.

    Article  PubMed  Google Scholar 

  31. Morin RL, Coombs LP, Chatfield MB. ACR dose index registry. J Am Coll Radiol JACR. 2011;8:288–91.

    Article  Google Scholar 

  32. Techasith T, Cury RC. Stress myocardial CT perfusion: an update and future perspective. JACC Cardiovasc Imaging. 2011;4:905–16.

    Article  PubMed  Google Scholar 

  33. Shantouf RS, Mehra A. Coronary fractional flow reserve. AJR Am J Roentgenol. 2015;204:W261–5.

    Article  PubMed  Google Scholar 

Download references

Compliance with Ethics Guidelines

Conflict of Interest

CD Maroules, RC Cury, BB Ghoshhajra, U Hoffmann, HI Litt, R Blankstein, and S Abbara all declare no conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Author information

Authors and Affiliations

  1. Department of Radiology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX, 75390-8896, USA

    Christopher D. Maroules & Suhny Abbara

  2. Department of Radiology, Baptist Hospital of Miami and Baptist Cardiac and Vascular Institute, Miami, FL, USA

    Ricardo C. Cury

  3. Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA

    Brian B. Ghoshhajra & Udo Hoffmann

  4. Department of Radiology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA

    Harold I. Litt

  5. Noninvasive Cardiovascular Imaging Program, Departments of Medicine and Radiology, Brigham and Women’s Hospital, Boston, MA, USA

    Ron Blankstein

Authors
  1. Christopher D. Maroules
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Ricardo C. Cury
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Brian B. Ghoshhajra
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Udo Hoffmann
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Harold I. Litt
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Ron Blankstein
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Suhny Abbara
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Christopher D. Maroules.

Additional information

This article is part of the Topical Collection on Cardiac Computed Tomography

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Maroules, C.D., Cury, R.C., Ghoshhajra, B.B. et al. Strategy for Building a Successful Coronary CT Angiography Program in the Emergency Department. Curr Cardiovasc Imaging Rep 8, 21 (2015). https://doi.org/10.1007/s12410-015-9337-x

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s12410-015-9337-x

Keywords

Search

Navigation