Coronary CT Angiography Versus Standard Emergency Department Evaluation for Acute Chest Pain and Diabetic Patients: Is There Benefit With Early Coronary CT Angiography? Results of the Randomized Comparative Effectiveness ROMICAT II Trial

J Am Heart Assoc. 2016 Mar 22;5(3):e003137. doi: 10.1161/JAHA.115.003137.


Background: Cardiac computed tomography angiography (CCTA) reduces emergency department length of stay compared with standard evaluation in patients with low- and intermediate-risk acute chest pain. Whether diabetic patients have similar benefits is unknown.

Methods and results: In this prespecified analysis of the Rule Out Myocardial Ischemia/Infarction by Computer Assisted Tomography (ROMICAT II) multicenter trial, we randomized 1000 patients (17% diabetic) with symptoms suggestive of acute coronary syndrome to CCTA or standard evaluation. The rate of acute coronary syndrome was 8% in both diabetic and nondiabetic patients (P=1.0). Length of stay was unaffected by the CCTA strategy for diabetic patients (23.9 versus 27.2 hours, P=0.86) but was reduced for nondiabetic patients compared with standard evaluation (8.4 versus 26.5 hours, P<0.0001; P interaction=0.004). CCTA resulted in 3-fold more direct emergency department discharge in both groups (each P≤0.0001, P interaction=0.27). No difference in hospital admissions was seen between the 2 strategies in diabetic and nondiabetic patients (P interaction=0.09). Both groups had more downstream testing and higher radiation doses with CCTA, but these were highest in diabetic patients (all P interaction≤0.04). Diabetic patients had fewer normal CCTAs than nondiabetic patients (32% versus 50%, P=0.003) and similar normalcy rates with standard evaluation (P=0.70). Notably, 66% of diabetic patients had no or mild stenosis by CCTA with short length of stay comparable to that of nondiabetic patients (P=0.34), whereas those with >50% stenosis had a high prevalence of acute coronary syndrome, invasive coronary angiography, and revascularization.

Conclusions: Knowledge of coronary anatomy with CCTA is beneficial for diabetic patients and can discriminate between lower risk patients with no or little coronary artery disease who can be discharged immediately and higher risk patients with moderate to severe disease who warrant further workup.

Clinical trial registration: URL: Unique identifier: NCT01084239.

Keywords: acute coronary syndrome; cardiac computed tomography; chest pain diagnosis; diabetes mellitus; emergency department.

Publication types

  • Comparative Study
  • Multicenter Study
  • Randomized Controlled Trial
  • Research Support, N.I.H., Extramural

MeSH terms

  • Acute Coronary Syndrome / complications
  • Acute Coronary Syndrome / diagnostic imaging*
  • Adult
  • Aged
  • Angina Pectoris / diagnostic imaging*
  • Angina Pectoris / etiology
  • Cardiology Service, Hospital*
  • Coronary Angiography / methods*
  • Coronary Artery Disease / complications
  • Coronary Artery Disease / diagnostic imaging*
  • Diabetic Angiopathies / complications
  • Diabetic Angiopathies / diagnostic imaging*
  • Emergency Service, Hospital*
  • Female
  • Humans
  • Length of Stay
  • Male
  • Middle Aged
  • Patient Discharge
  • Predictive Value of Tests
  • Risk Assessment
  • Risk Factors
  • Severity of Illness Index
  • Time Factors
  • Tomography, X-Ray Computed*
  • United States

Associated data