The ROMICAT 2 trial: Coronary computed tomographic angiography shortens hospital stays for acute chest pain [Classics Series]

The following study summary is an excerpt from the book 2 Minute Medicine’s The Classics in Radiology: Summaries of Clinically Relevant & Recent Landmark Studies, 1e (The Classics Series).

1. In patients presenting to the emergency department with acute chest pain, evaluation with computed tomographic coronary angiography (CTCA) led to significantly shorter hospital stays compared to the standard care without CTCA.

2. There were no undetected acute coronary syndromes (ACSs) in either group, and no significant difference between the groups in the rate of major adverse cardiovascular events (MACE) at 28 days. 

Original Date of Publication: July 2012 

Study Rundown: The Rule Out Myocardial Infarction/Ischemia Using Computer Assisted Tomography 1 (ROMICAT 1) trial was a prospective cohort study that demonstrated the high sensitivity and negative predictive value of CTCA in patients with low to intermediate risk of ACS. The ROMICAT 2 trial was a randomized controlled trial that compared a strategy incorporating CTCA with standard care in assessing patients presenting to the emergency department with chest pain. Patients in the CTCA group experienced significantly shorter hospital stays and higher rates of direct discharge from the emergency department compared to those receiving standard care. Moreover, there were no cases of undetected ACS in either group, and no significant difference in the rate of major adverse cardiovascular events (MACE) at 28 days after the index visit.

In-Depth [randomized controlled trial]: The study involved 1000 patients recruited from 9 centers across the U.S. who were randomized in a 1:1 ratio to evaluation involving CTCA or to standard evaluation. Patients were eligible for the trial if they were 40-74 years of age, had chest pain or an angina equivalent lasting >5 minutes in the 24 hours prior to presenting, and warranted further risk stratification to rule out acute coronary syndrome (ACS) according to the assessing physician. Exclusion criteria included history of known coronary artery disease, new diagnostic ischemic changes on the initial electrocardiogram (ECG), initial elevated troponin, creatinine >132.6 μmol/L (>1.5 mg/dL), iodine contrast allergy, and body mass index >40.

At least 64-slice CT technology was required, and both retrospectively ECG-gated and prospectively ECG-triggered CTCAs were allowed. The primary endpoint was length of hospital stay. Secondary endpoints included time to diagnosis, rate of direct discharge from the emergency department, and resource utilization. The secondary safety endpoints were undetected ACS and MACE (death, myocardial infarction, unstable angina, or urgent coronary revascularization) within 28 days, and periprocedural complications (stroke, bleeding, anaphylaxis, renal failure).

The mean length of hospitalization was 7.6 hours shorter for patients in the CTA group compared to those undergoing standard evaluation (p < 0.001). Patients undergoing CTCA also experienced significantly shorter time to diagnosis (p < 0.001), and had significantly higher rates of direct discharge from the emergency department (47% versus 12%, p < 0.001). There were no undetected ACSs and no significant differences between the groups in the rate of MACE at 28 days (p = 0.18) or periprocedural complications (p = 0.50).

Patients in the CTA group had significantly higher rates of diagnostic testing (p < 0.001) and functional testing (p < 0.001) than those in the standard group. Moreover, there was a trend towards higher rates of coronary angiography (p = 0.06) and revascularization (p = 0.16) in those who underwent CTCA, though the costs of care were not significantly different between the two groups for the index visit and follow-up period (p = 0.65).

Click to read the study in NEJMac

Hoffmann U, Truong QA, Schoenfeld DA, Chou ET, Woodard PK, Nagurney JT, et al. Coronary CT Angiography versus Standard Evaluation in Acute Chest Pain. The New England Journal of Medicine. 2012 Jul 26;367(4):299–308.

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