Diagnostic performance of coronary CTA versus exercise electrocardiography in acute chest pain: A propensity score-matched study in the emergency department

Purpose: To compare the clinical impact and operational efficiency of exercise electrocardiography (ex-ECG) and coronary CT angiography (CCTA) in the diagnostic-therapeutic care pathway of patients presenting to the Emergency Department (ED) with acute chest pain (ACP) and suspected non-ST-elevation acute coronary syndrome (NSTE-ACS). Methods: This single-center retrospective cohort study enrolled 428 consecutive patients presenting with ACP between January 2022 and December 2023. After propensity score matching (PSM) for age, sex, Heart Score, and triage code, two balanced groups of 214 patients each underwent either -ex-ECG or CCTA. Primary outcomes included diagnostic test positivity, hospital admission rate, and ED length-stay. Secondary outcomes included need for invasive coronary angiography (ICA) and revascularization rates. Results: No statistically significant differences were found in test positivity (42 vs 31 patients, p = 0.157) or hospital admission rates (42 vs 30 patients, p = 0.121) between ex-ECG and CCTA groups. The ICA rates were similar (36 vs 32 patients, p = 0.597), as were revascularization rates (13 patients each, p = 1.000). However, discharged patients undergoing CCTA had significantly shorter total ED length-stay compared to ex-ECG (1710 vs 1841 min, p < 0.001), representing a 7.12 % reduction. Conclusion: Both ex-ECG and CCTA demonstrate comparable clinical impact and operational efficiency in patients with ACP and suspected NSTE-ACS. CCTA offers effective advantages with significantly reduced ED length-stay for a safe discharge of the patients, improving resource management without compromising diagnostic quality. These findings support the increasing adoption of CCTA in the diagnostic pathway for ACP and suspected NSTE-ACS in the ED setting.