Clinical and Economic Effectiveness of CT Angiography Methods in the Emergency Department for Intermediate-Risk Patients With Non-ST-Segment Elevation Acute Coronary Syndrome

Abstract

Aim. The aim of this study was to evaluate the clinical and cost-effectiveness of computed tomography angiography (CTA), which includes CT coronary angiography and a “triple rule-out” protocol, in intermediate-risk patients with suspected non-ST-segment elevation acute coronary syndrome (NSTEACS) in the emergency room (ER) of the regional vascular center in the structure of a multidisciplinary hospital in Moscow.Material and methods. This continuous single-site study included patients hospitalized in a multidisciplinary hospital with a referral diagnosis of NSTEACS within 69 days. Patients at intermediate risk who met the inclusion criteria underwent CTA after the initial examination in the ER. If coronary artery disease or an alternative significant diagnosis was excluded, patients were discharged from the hospital on the day of admission. As a comparison method, the costs of treating these patients were assessed if a standard protocol was used. According to this protocol, patients, after the initial examination, were hospitalized in the intensive care unit for patients with myocardial infarction (ICU-MI) and then in the cardiology department for observation and further examination. Clinical economic analysis was performed using the cost minimization method and the tariff method of cost estimation.Results. For 69 days, 289 patients (59.5% men, mean age 71.7±8.6 years) were admitted to the ER with a referral diagnosis of NSTEACS. In 30 of them, a non-cardiological disease was identified that required routing to other specialized units. 37 (14.3%) of intermediate-risk patients underwent CTA. In 27 of them (10% of all patients), no significant coronary stenosis, signs of pulmonary embolism (PE), or aortic dissection were detected, and the patients were discharged from the ER. 10 patients (4% of all patients) who had significant coronary artery stenoses, PE, or aortic dissection were hospitalized. 72 intermediate-risk patients had exclusion criteria for CTA. The economic benefit from using CTA for excluding ACS in the ER, as compared to the standard approach, was 1,602,450 rubles for the study period. The estimated benefit per year was 8,476,728 rubles.Conclusion. The introduction of CTA and the “triple rule-out” protocol for intermediate-risk patients in the ER can significantly improve the process of excluding the diagnosis of NSTEACS, reduce the number of unnecessary hospitalizations and optimize the use of hospital capacity. According to the results of our study, this approach is applicable in at least 14% of patients with suspected NSTEACS (at least 33% of intermediate-risk patients).