Patient Care

CT Angiography Effect on Outcome for Patients with Symptomatic Chest Pain


 

Clinical question: Does CT angiography (CTA) improve clinical outcomes in patients with new-onset stable chest pain more than functional testing?

Background: Chest pain is a common clinical problem, and multiple noninvasive tests are available to detect coronary artery disease (CAD). CT angiography is more accurate than noninvasive testing and may decrease unnecessary invasive testing and improve outcomes in patients with new-onset stable chest pain.

Study design: Pragmatic, comparative-effectiveness design.

Setting: One hundred ninety-three North American sites.

Synopsis: Ten thousand three symptomatic outpatients, mean age 60 years, with at least one cardiovascular risk factor, were randomized to CTA or functional testing to detect CAD. Primary endpoints including death, myocardial infarction, hospitalization for unstable angina, or major procedural complication occurred in 3.3% of CTA patients and 3.0% of functional testing patients (adjusted hazard ratio, 1.04; 95% confidence interval, 0.83 to 1.29; P=0.75). CTA patients received fewer catheterizations showing nonobstructive CAD (3.4% of versus 4.3%, P=0.02).

More CTA patients underwent catheterization within 90 days after randomization (12.2% vs 8.1%), however. Patients in the CTA group had higher exposures to radiation overall, but, per patient, their mean cumulative radiation dose was lower than that of the functional testing group (10.0 mSv vs. 11.3 mSv).

Interestingly, 6.2% of CTA patients versus 3.2% of functional testing patients underwent revascularization, but the study was not powered to assess invasive catheterization or revascularization rates on outcomes.

This study is interesting because results are generalizable to real-world settings; CTA did not improve outcomes compared to functional testing in patients undergoing testing for CAD.

Bottom line: No improvement was seen in clinical outcomes for symptomatic patients undergoing evaluation for CAD with CTA compared with those receiving functional testing.

Citation: Douglas PS, Hoffmann U, Patel MR, et al. Outcomes of anatomical versus functional testing for coronary artery disease. N Engl J Med. 2015;372(14):1291-1300.

Short Takes

NO CHANGE IN PATIENT SAFETY OR RESIDENT WELL-BEING WITH SHORTER RESIDENT SHIFTS IN ICU

Synopsis: Randomized trial showed no difference among 24-, 16-, or 12-hour resident duty shifts and mortality rate, number of adverse events in the ICU, or resident sleepiness or well-being.

Citation: Parshuram CS, Amaral AC, Ferguson ND, et al. Patient safety, resident well-being and continuity of care with different resident duty schedules in the intensive care unit: a randomized trial. CMAJ. 2015;187(5):321-329.


DISTRACTIONS DURING RESIDENT HANDOFFS DO NOT AFFECT QUALITY

Synopsis: Although distractions such as pages and telephone calls were present in 48% of resident handoffs, they did not negatively impact the quality of resident handoffs.

Citation: Anderson CE, Nicksa GA, Stewart L. Distractions during resident handoffs: Incidence, sources, and influence on handoff quality and effectiveness [published ahead of print March 4, 2015]. JAMA Surg.


DISSATISFIED PHYSICIANS LESS ENTHUSIASTIC ABOUT GIVING CHARITY CARE

Synopsis: Physicians reporting moderate to severe fatigue were less satisfied with practicing medicine. Dissatisfied physicians reported lower perceived obligation to care for underserved patients or to see health policy in their scope of practice.

Citation: O’Donnell EP, Humeniuk KM, West CP, Tilburt JC. The effects of fatigue and dissatisfaction on how physicians perceive their social responsibilities. Mayo Clin Proc. 2015;90(2):194-201.

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