Coronary Computed Tomography Angiography for Early Triage of Patients With Acute Chest Pain

Abstract

Objectives To determine the usefulness of coronary computed tomography angiography (CTA) in patients with acute chest pain. Background Triage of chest pain patients in the emergency department (ED) remains challenging. Methods Observational cohort study in chest pain patients with normal initial troponin and non-ischemic electrocardiogram. 64-slice coronary CTA was performed prior to admission to detect coronary plaque and stenosis (>50% luminal narrowing). Results were not disclosed. Endpoints were acute coronary syndrome (ACS) during index hospitalization and major adverse cardiac events (MACE) during 6- month follow-up. Results Among 368 patients (mean age 53±12 years, 61% male) 31 had ACS (8%). By coronary CTA, 50% of these patients were free of CAD, 31% had nonobstructive disease, and 19% had inconclusive or positive CT for significant stenosis. Sensitivity and negative predictive value (NPV) for ACS were 100% (n=183/368; 95% confidence interval [CI]: 98 to 100%) and 100% (95%-CI: 0.89–1.00) with the absence of CAD; and 77% (95% CI: 59–90%) and 98% (n=300/368, 95%-CI: 95–99%) with significant stenosis by coronary CTA. Specificity of presence of plaque and stenosis for ACS were 54% (95%-CI: 0.49–0.60) and 87% (95%-CI: 0.83–0.90); respectively. Only one ACS occurred in the absence of calcified plaque. Both, the extent of coronary plaque and presence of stenosis predicted ACS independently and incrementally to TIMI risk score (AUC: 0.88, 0.82 vs. 0.63; respectively, all p<0.0001). Conclusion Fifty percent of patients with acute chest pain and low to intermediate likelihood of ACS are free of CAD by CT and have no ACS. Given the large number of such patients early coronary CTA may significantly improve patient management in the emergency department.

Emergency physician estimates of the probability of acute coronary syndrome in a cohort of patients enrolled in a study of coronary computed tomographic angiography

“…The ROMICAT study was a study of CCTA in low-risk patients admitted with chext pain, in which all subjects received CCTA; the results were not provided to clinicians and did not influence in-patient management decisions. 31,32 The Institutional Review Board of Partners Health Care approved the study. Patients provided written consent, and the consent of providers answering our research questionnaire was implicit.…”

Associations between thyroid hormone levels and regional fat accumulation in euthyroid men

“…Adipose tissue area ranged from K250 to K50 HU. The mid-thigh skeletal muscle area was compartmentalized into areas of normal-density muscle (C31 to C100 HU) and low-density muscle (0 to C30 HU) (13).…”

Chest pain: coronary CT in the ER

“…The study showed an excellent NPV (98%) of significant stenosis for exclusion of ACS, but a low PPV (35%), since approximately 50% of patients with obstructive CAD or inconclusive assessment at cardiac CT were finally diagnosed with ACS. 70 Furthermore, the limited sensitivity owing to a number of patients who were false negative (77%, n 5 7 of 31) may be explained by the limited accuracy of cardiac CT to detect stenosis in small-calibre vessels (,2 mm); rupture or thrombosis in subcritical CAD or microvascular disease. 70 However, the excellent NPV (.98%) was uniformly demonstrated in most of the series evaluating population with ACP.…”

“…70 Furthermore, the limited sensitivity owing to a number of patients who were false negative (77%, n 5 7 of 31) may be explained by the limited accuracy of cardiac CT to detect stenosis in small-calibre vessels (,2 mm); rupture or thrombosis in subcritical CAD or microvascular disease. 70 However, the excellent NPV (.98%) was uniformly demonstrated in most of the series evaluating population with ACP. A study including nearly 600 patients at ED with low risk (TIMI risk score 0-2), of whom 84% patients were discharge based on a negative cardiac CT, likewise demonstrated a NPV of 100% for adverse events within 30 days.…”

“…67,68,70,73 For that reason, different strategies have been implemented to improve the specificity and PPV of the cardiac CT examination; among these, the two most relevant are evaluation of plaque morphology, MPI and fractional flow reserve (FFR) derived from CT.…”