This retrospective dredge of the ROMICAT-II trial found that clinical evaluation alone had decreased length of stay (LOS) and appeared to be as safe with respect to major adverse coronary events as those who had non-invasive testing, with lower cost and radiation exposure.
Why does this matter?
ROMICAT-II found that patients with concerning chest pain but negative ECG and troponin had LOS about 7.5 hours shorter in the CCTA group vs usual care (which included a mix of clinical assessment +/- other non-invasive testing per local physician discretion). This study singled out the small subset with no non-invasive testing at all, only clinical assessment, and looked at their LOS.
Take this study for what it's worth, which is a retrospective dredge of the ROMICAT-II RCT data. It may find association, but the original study was not designed to find these outcomes. With that said, they looked at 1000 patients who had clinical assessment alone or clinical assessment plus CCTA or other non-invasive testing of some kind. Only 12% had clinical assessment alone, meaning no CCTA or any other kind of functional study, like stress echo or nuclear study. There was no defined clinical risk stratification scoring system used; this was at the discretion of the local physicians. The primary outcome, LOS, was less in the clinical assessment group by 7.5 hours. So ROMICAT-II found that CCTA reduced LOS by 7.5 hours vs usual care; this study found clinical assessment alone reduced LOS by 7.5 hours vs patients who received any kind of non-invasive testing. For secondary outcomes (which seem more important to me) including MACE, this appeared to be a safe practice: (2% no-testing vs 1% with non-invasive testing; P = .24). They also found the no-testing group had lower cost, radiation exposure, and incidence of further invasive testing and intervention.
Noninvasive Cardiac Testing vs Clinical Evaluation Alone in Acute Chest Pain: A Secondary Analysis of the ROMICAT-II Randomized Clinical Trial. JAMA Intern Med. 2017 Nov 14. doi: 10.1001/jamainternmed.2017.7360. [Epub ahead of print]
Peer reviewed by Thomas Davis, MD.