Use of Electron-Beam Computed Tomography in the Evaluation of Chest Pain Patients in the Emergency Department

Laudon, Dennis A.; Vukov, Larry F.; Breen, Jerome F.; Rumberger, John A.; Wollan, Peter C.; Sheedy, Patrick F.

doi:10.1016/s0196-0644(99)70412-9

Cited by 171 publications

(74 citation statements)

References 31 publications

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“…25 Coronary artery stenoses are rare in patients without CAC in most studies. 15,26 However, Rubinshtein et al 27 found that CAD was evident on cardiac CT angiography (CTA) in 7% of patients with CAC scores of 0. These data are not directly comparable to the findings of our study because of the differences in study populations and end points.…”

Section: Discussionmentioning

confidence: 99%

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Computed Tomographic Coronary Artery Calcium Assessment for Evaluating Chest Pain in the Emergency Department: Long-term Outcome of a Prospective Blind Study

Laudon¹,

Behrenbeck²,

Wood

et al. 2010

Mayo Clinic Proceedings

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For editorial comment, see page 309 C hest pain is the presenting concern for more than 8 million emergency department (ED) visits annually. The ED evaluation of chest pain is resource-intense and has inherent limitations. Medical history and physical examination frequently yield little insight into the source of the chest pain. More than one-third of patients with docu- OBJECTIVE: To determine the long-term outcome of computed tomographic (CT) quantification of coronary artery calcium (CAC) used as a triage tool for patients presenting with chest pain to an emergency department (ED). PATIENTS AND METHODS:Patients (men aged 30-62 years and women aged 30-65 years) with chest pain and low-to-moderate probability of coronary artery disease underwent both conventional ED chest pain evaluation and CT CAC assessment prospectively. Patients' physicians were blinded to the CAC results. The results of the conventional evaluation were compared with CAC findings on CT, and the long-term outcome in patients undergoing CT CAC assessment was established. Primary end points (acute coronary syndrome, death, fatal or nonfatal non-ST-segment elevation myocardial infarction, fatal or nonfatal ST-segment elevation myocardial infarction) and secondary outcomes (coronary artery bypass grafting, percutaneous transluminal coronary angioplasty, coronary stenting, or a combination thereof) were obtained when the patient was dismissed from the ED or hospital and then at 30 days, 1 year, and 5 years. RESULTS:Of the 263 study patients, 133 (51%) had a CAC score of zero. This absence of CAC correlated strongly with the likelihood of noncardiac chest pain. Among 133 patients with a CAC score of zero, only 1 (<1%) had cardiac chest pain. Conversely, of the 31 patients shown to have cardiac chest pain, 30 (97%) had evidence of CAC on CT. When a CAC cutoff score of 36 was used, as suggested by receiver operating characteristic analysis, sensitivity was 90%; specificity, 85%; positive predictive value, 44%; and negative predictive value, 99%. During long-term follow-up, patients without CAC experienced no cardiac events at 30 days, 1 year, and 5 years.CONCLUSION: Findings suggest that CT CAC assessment is a powerful adjunct in chest pain evaluation for the population at low-tointermediate risk. Absent or minimal CAC in this population makes cardiac chest pain extremely unlikely. The absence of CAC suggests an excellent long-term (5-year) prognosis, with no primary or secondary cardiac outcomes ocurring in study patients at 5-year follow-up. Proc. 2010;85(4):314-322 ACS = acute coronary syndrome; CAC = coronary artery calcium; CAD = coronary artery disease; CI = confidence interval; CT = computed tomography; CTA = CT angiography; ECG = electrocardiography; ED = emergency department; IQR = interquartile range; MDCT = multidetector CT; MI = myocardial infarction; ROC = receiver operating characteristic mented acute myocardial infarctions (MIs) lack chest pain on presentation. Mayo Clin2 Resting 12-lead electrocardiography (ECG) has limited value in ...

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Section: Discussionmentioning

confidence: 99%

“…10,15 Our study evaluates the integration of cardiac CT for CAC detection into the assessment and triage of patients with chest pain in the ED and examines its value in long-term outcome in patients.…”

Section: Mayo Clinmentioning

confidence: 99%

Computed Tomographic Coronary Artery Calcium Assessment for Evaluating Chest Pain in the Emergency Department: Long-term Outcome of a Prospective Blind Study

Laudon¹,

Behrenbeck²,

Wood

et al. 2010

Mayo Clinic Proceedings

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“…Electron beam computer tomography had excellent negative predictive value but low specificity in patients with chest pain. 30,31 MRI surmounts some of these barriers. Many hospitals have MRI capability for other emergencies such as stroke.…”

Section: Discussionmentioning

confidence: 99%

Detecting Acute Coronary Syndrome in the Emergency Department With Cardiac Magnetic Resonance Imaging

et al. 2003

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Background-Managing chest pain in the emergency department remains a challenge with current diagnostic strategies.We hypothesized that cardiac MRI could accurately identify patients with possible or probable acute coronary syndrome. Methods and Results-The diagnostic performance of MRI was evaluated in a prospective study of 161 consecutive patients. Enrollment required 30 minutes of chest pain compatible with myocardial ischemia but an ECG not diagnostic of acute myocardial infarction. MRI was performed at rest within 12 hours of presentation and included perfusion, left ventricular function, and gadolinium-enhanced myocardial infarction detection. MRI was interpreted qualitatively but also analyzed quantitatively. The sensitivity and specificity, respectively, for detecting acute coronary syndrome were 84% and 85% by MRI, 80% and 61% by an abnormal ECG, 16% and 95% for strict ECG criteria for ischemia (ST depression or T-wave inversion), 40% and 97% for peak troponin-I, and 48% and 85% for a TIMI risk score Ն3. The MRI was more sensitive than strict ECG criteria for ischemia (PϽ0.001), peak troponin-I (PϽ0.001), and the TIMI risk score (Pϭ0.004), and MRI was more specific than an abnormal ECG (PϽ0.001). Multivariate logistic regression analysis showed MRI was the strongest predictor of acute coronary syndrome and added diagnostic value over clinical parameters (PϽ0.001). Conclusions-Resting

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“…In a study of 568 low-risk ED patients with chest pain, those with negative coronary CTA did not have any adverse outcomes (nonfatal AMI or death) within 30 days of the index ED visit [25]. Prior studies have shown that coronary CTA has high diagnostic accuracy (82-100% sensitivity, 82-98% specificity, negative predictive value of 95-100%) in low-risk patients for detection of coronary artery disease [26][27][28][29][30][31][32][33][34]. Coronary CTA has been shown to be as safe [17] and more cost effective [18] than other methods of evaluating these patients.…”

Section: Discussionmentioning

confidence: 99%

Coronary computerized tomography angiography for rapid discharge of low-risk patients with cocaine-associated chest pain

et al. 2009

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Background: Most patients presenting to emergency departments (EDs) with cocaine-associated chest pain are admitted for at least 12 hours and receive a "rule out acute coronary syndrome" protocol, often with noninvasive testing prior to discharge. In patients without cocaine use, coronary computerized tomography angiography (CTA) has been shown to be useful for identifying a group of patients at low risk for cardiac events who can be safely discharged. It is unclear whether a coronary CTA strategy would be efficacious in cocaine-associated chest pain, as coronary vasospasm may account for some of the ischemia. We studied whether a negative coronary CTA in patients with cocaine-associated chest pain could identify a subset safe for discharge.Methods: We prospectively evaluated the safety of coronary CTA for low-risk patients who presented to the ED with cocaineassociated chest pain (self-reported or positive urine test). Consecutive patients received either immediate coronary CTA in the ED (without serial markers) or underwent coronary CTA after a brief observation period with serial cardiac marker measurements. Patients with negative coronary CTA (maximal stenosis less than 50%) were discharged. The main outcome was 30-day cardiovascular death or myocardial infarction.Results: A total of 59 patients with cocaine-associated chest pain were evaluated. Patients had a mean age of 45.6 Ϯ 6.6 yrs and were 86% black, 66% male. Seventy-nine percent had a normal or nonspecific ECG and 85% had a TIMI score <2. Twenty patients received coronary CTA immediately in the ED, 18 of whom were discharged following CTA (90%). Thirty-nine received coronary CTA after a brief observation period, with 37 discharged home following CTA (95%). Six patients had coronary stenosis Ն50%. During the 30-day follow-up period, no patients died of a cardiovascular event (0%; 95% CI, 0-6.1%) and no patient sustained a nonfatal myocardial infarction (0%; 95% CI, 0-6.1%).Conclusions: Although cocaine-associated myocardial ischemia can result from coronary vasoconstriction, patients with cocaineassociated chest pain, a non-ischemic ECG, and a TIMI risk score <2 may be safely discharged from the ED after a negative coronary CTA with a low risk of 30-day adverse events.

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Use of Electron-Beam Computed Tomography in the Evaluation of Chest Pain Patients in the Emergency Department

Cited by 171 publications

References 31 publications

Computed Tomographic Coronary Artery Calcium Assessment for Evaluating Chest Pain in the Emergency Department: Long-term Outcome of a Prospective Blind Study

Computed Tomographic Coronary Artery Calcium Assessment for Evaluating Chest Pain in the Emergency Department: Long-term Outcome of a Prospective Blind Study

Detecting Acute Coronary Syndrome in the Emergency Department With Cardiac Magnetic Resonance Imaging

Coronary computerized tomography angiography for rapid discharge of low-risk patients with cocaine-associated chest pain

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