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Introduction Emergency chest pain presentations represent a significant cost burden to the health service. Prior studies have shown the use of coronary computed tomography angiography (CCTA) in stable outpatients referred for invasive coronary angiography (ICA) to be safe and cost-effective. We aimed to describe the cost benefit of an accelerated outpatient CCTA pathway compared with inpatient ICA for the investigation of patients presenting acutely to the emergency department (ED) with symptoms suggestive of coronary artery disease (CAD) at a tertiary referral centre.Methods A cost analysis was performed based on retrospective observational data including stable adult ED patients referred to the outpatient CCTA pathway (HEART score 0–3) or admitted for ICA (HEART score >3) at St James’s Hospital in 2023. Patients with ST-elevation myocardial infarction were excluded.Results 745 patients were included ( table 1). 369 patients (49.5%) underwent outpatient CCTA and 376 (50.5%) were admitted for ICA. The median time to outpatient CCTA was 14 days (IQR 5–24). There was an estimated saving of 78% per patient (€2990) through use of the CCTA pathway for the investigation of lower-risk individuals (figure 1), accounting for an annual saving of €1.1 million, with no increase in 30-day mortality or myocardial infarction. Patients referred for outpatient CCTA had a significantly shorter median hospital length-of-stay compared with those admitted for ICA [6.5 hours (IQR 5–9) vs 5 days (IQR 3–14.9), p<0.001], resulting in an estimated 1845 bed-days spared in 2023. 88 patients (23%) admitted for ICA had negative troponin levels and did not require revascularisation, at an estimated total cost of €338,272.Conclusion Use of an accelerated outpatient CCTA pathway in the ED setting resulted in significant savings without compromising patient safety. Our analysis also highlights the potential for further cost reduction via improved access to outpatient cardiac magnetic resonance perfusion imaging ( figure 2, table 2).Abstract 7 Table 1Characteristics of CCTA population and ICA population. Continuous results are expressed as a median (with interquartile range), and categorical variables are expressed as a total (with percentage) CCTA (N = 369) ICA (N = 376) Age 52 (44–59.5) 65 (59–73) <0.001 Gender Male = 198 (53.7%)Female = 171 (46.3%) Male = 262 (69.9%)Female = 113 (30.1%) <0.001 Family history of IHD 206 (56.94%) 121 (32.3%) <0.001 Hypertension 122 (33%) 228 (60.8%) <0.001 T2DM 34 (9.2%) 87 (26.1%) <0.001 T1DM 2 (0.05%) 3 (0.8%) >0.99 Smoker Current = 96 (26%)Ex = 92 (24.9%) Current = 90 (24%)Ex = 150 (40%) 0.512 <0.001 Dyslipidaemia 163 (44.2%) 230 (61.3%) <0.001 Vascular disease 10 (2.7%) 158 (42.1%) <0.001 Systolic BP 133 (120–150) 137 (121–154) 0.195 Diastolic BP 80 (76–88) 78 (72–87) 0.003 Heart Rate 76 (68–87) 78 (68–90) 0.075 Electrocardiogram Normal = 323 (87.5%) Normal = 253 (67.5%) <0.001 Troponin Normal = 357 (96.7%) 20 (1–62) <0.001 Creatinine 72 (61–85) 81 (68–99) <0.001 Revascularization 9 (2.4%) - PCI = 6 - CABG = 3Pending angiography = 8 164 (43.7%)- PCI = 135 (36%)- CABG = 27 (7.2%) <0.001 pLAD/LMCA involvement 5 (1.4%) 85 (22.7%) <0.001 MI at 30 days 0 0 Death at 30 days 0 9 (2.4%) 0.004 IHD = Ischaemic Heart Disease, T2DM = Type-2 Diabetes Mellitus, T1DM = Type-1 Diabetes Mellitus, BP = Blood Pressure, pLAD = Proximal Left Anterior Descending artery, LMCA = Left Main Coronary Artery, MI = Myocardial InfarctionAbstract 7 Table 2Average cost of various services at St James’s hospital in 2023 Service Average cost per patient (€) Emergency Department attendance 521 Outpatient Coronary CT Angiography 210 Diagnostic invasive coronary angiography 1168 Inpatient bed on cardiology ward (per night) 431 Outpatient Cardiac MR Perfusion imaging 420 Abstract 7 Figure 1Average diagnostic cost per patient for those investigated via the outpatient CCTA pathway (n=369, blue) and via admission for ICA (n=376, red)Abstract 7 Figure 2Projected reduction in total diagnostic cost if outpatient comprehensive non-invasive testing (CCTA + cardiac magnetic resonance perfusion imaging, blue) had been utilised rather than ICA (red) for 88 patients admitted with negative troponin levels who did not require revascularisation