Should Dual-Source CT be the New Standard for ER CCTA Assessment of Acute Chest Pain?

Is beta blocker administration necessary to ensure heart rate control during coronary computed tomography angiography (CCTA) exams in the emergency department (ED) for patients with acute chest pain?

In a new retrospective study involving 509 patients (mean age of 52.1) who underwent CCTA exams for acute chest pain, researchers compared the use of a 64-detector single-source CT (SSCT) device with heart rate control in 205 patients versus dual-source CT (DSCT) without heart rate control in 304 patients. Oral beta blockers were administered in the SSCT group for patients with a heart rate above 65 beats per minute, according to the study, recently published in the American Journal of Roentgenology.

The researchers found no significant differences in median emergency department (ED) length of stay between DSCT (505 minutes) and SSCT (457 minutes). They also noted no significant differences in the frequency of emergent cardiology consults, invasive angiography, and coronary revascularization procedures.

However, the use of DSCT did result in a 27.8 percent higher frequency of good or excellent image quality (87.8 percent) in comparison to SSCT (60 percent) and a 4.7 percent lower frequency of non-diagnostic exams (1.6 percent versus 6.3 percent), according to the study. The researchers also found that CCTA exams performed with DSCT were completed in a median time of 95 minutes in comparison to 117 minutes for SSCT.

“Patients undergo coronary CTA in the ED because of their risk for acute coronary syndrome (ACS); thus, these patients are considered to require urgent care and receive priority access to resources in the ED such as beds, monitors, and medical personnel. If ACS can be quickly excluded or diagnosed by shortening the CT completion time, then downstream management processes can likewise be accelerated. Subsequently, resources may be efficiently redistributed among patients, improving overall ED process management,” wrote study co-author Young Joo Suh, M.D., Ph.D., who is affiliated with the Department of Radiology at Severance Hospital and the Center for Clinical Imaging Data Science at Yonsei University College of Medicine in Seoul, Korea, and colleagues.

(Editor’s note: For related content, see “Can an Emerging Radiomics Model Improve CT Angiography Assessment of Heart Attack Risk?,” “Deep Learning Improves CT Guidance for Revascularization of Coronary Total Occlusions” and “Could an Emerging Deep Learning Modality Enhance CCTA Assessment of Coronary Artery Disease?”)

The study authors attributed 80 percent of the reduction in CCTA examination time with DSCT to the lack of heart rate control. Suh and colleagues said the use of two X-ray tubes and corresponding detector arrays give DSCT a significant advantage over SSCT in terms of faster temporal resolution and prevention of motion artifact degradation of coronary artery imaging that can occur in patients with high heart rates.

“The present analysis builds upon prior work indicating that the use of a DSCT system has the potential to avoid need for strict (heart rate) control for coronary CTA examinations,” maintained Suh and colleagues.

In regard to study limitations, the authors cautioned about general extrapolation of the study findings as they were drawn from research conducted at a single tertiary facility during the COVID-19 pandemic. The study cohort included patients with low to intermediate risk for acute coronary syndrome (ACS) but the researchers acknowledged that guidelines for the assessment of chest pain that were published during the study noted that routine testing for ACS is not necessary for low-risk patients with chest pain presenting to emergency departments. Other than temporal resolution, the study authors noted they did not evaluate technical parameter differences between DSCT and SSCT.