Impact of 64-slice coronary CT on the management of patients presenting with acute chest pain: results of a prospective two-centre study

Background: Coronary computed tomography (CT) may improve the early triage of patients with acute chest pain in the emergency department (ED). The aim of this study was to compare the presence and extent of coronary atherosclerotic plaque as detected by coronary CT in patients with and without acute coronary syndromes (ACS). Methods: The study was designed as a prospective, observational cohort study in patients with acute chest pain but negative cardiac biomarkers and no diagnostic ECG changes, admitted to rule out myocardial ischemia. All patients underwent coronary CT prior to hospital admission. The presence of coronary plaque was treated as a dichotomous outcome, and the extent of CAD was defined as number of (1) coronary segments with plaque, or (2) major coronary arteries with plaque detected by MDCT as assessed by two independent observers. The clinical outcome (ACS) was adjudicated by a review committee using established AHA criteria; subjects with history of CAD (stent placement, bypass) were excluded. Results : Among 368 patients with acute chest pain (mean age 53±12 years, 61% male) 31 patients were determined to have ACS (8%). None of the 183 subjects without plaque (50%) had an ACS. Among the remaining 185 subjects (mean age 58.0±11.5 years, 68% male) in whom coronary plaque was detected, patients with ACS had a significantly more plaque (7.2±3.7 vs. 4.2±3.4, p<0.0001 segments) as compared to subjects without ACS. Similar results were seen for calcified plaque and non-calcified plaque (6.5±3.7 vs. 3.6±3.5 segments, p<0.0001; and 3.6±3.2 vs. 1.8±2.2 segments, p<0.0001, respectively). In addition, the rate of ACS increased with the number of major coronary arteries with plaque (1-vessel: 6.8%, 2-vessels: 10.6%, 3 vessels: 30.8%, and 4-vessels: 25%; p<0.01). In contrast, the ratio of non-calcified to calcified plaque was not different between patients with and without ACS (0.68±0.6 vs. 0.54±0.72, p=0.31). Conclusions: The extent of coronary plaque differs between subjects with and without ACS among patients presenting with acute chest pain. Detailed assessment of the extent and composition of coronary plaque may be helpful to assess risk of ACS among patients with acute chest pain but inconclusive initial ED evaluation.

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High-Risk Plaque Detected on Coronary CT Angiography Predicts Acute Coronary Syndromes Independent of Significant Stenosis in Acute Chest Pain: Results from the Romicat-II Trial

Journal of Emergency Medicine ◽

10.1016/j.jemermed.2014.11.013 ◽

2015 ◽

Vol 48 (1) ◽

pp. 130

Author(s):

Stephanie Oberfoell

Keyword(s):

Chest Pain ◽

High Risk ◽

Ct Angiography ◽

Acute Coronary Syndromes ◽

Coronary Ct Angiography ◽

Acute Chest Pain ◽

Significant Stenosis ◽

Coronary Ct ◽

Coronary Syndromes

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Coronary CT angiography decreases the length of stay in emergency department versus standard therapy in patients presenting with acute chest pain, but results in increased downstream testing and radiation exposure

Evidence-Based Medicine ◽

10.1136/eb-2012-101011 ◽

2012 ◽

Vol 18 (4) ◽

pp. 146-147 ◽

Cited By ~ 2

Author(s):

James K Min ◽

Reza Arsanjani

Keyword(s):

Emergency Department ◽

Chest Pain ◽

Length Of Stay ◽

Radiation Exposure ◽

Ct Angiography ◽

Standard Therapy ◽

Coronary Ct Angiography ◽

Acute Chest Pain ◽

Coronary Ct

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Coronary CT Angiography in Acute Chest Pain Syndromes

Current Cardiovascular Imaging Reports ◽

10.1007/s12410-010-9052-6 ◽

2010 ◽

Vol 3 (6) ◽

pp. 382-389

Author(s):

Kavitha M. Chinnaiyan ◽

Ryan D. Madder ◽

James A. Goldstein

Keyword(s):

Chest Pain ◽

Ct Angiography ◽

Coronary Ct Angiography ◽

Acute Chest Pain ◽

Coronary Ct ◽

Pain Syndromes

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Faculty Opinions recommendation of Coronary CT angiography versus standard evaluation in acute chest pain.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.717954171.793533668 ◽

2017 ◽

Author(s):

Arthur Stillman ◽

Nikhil Goyal

Keyword(s):

Chest Pain ◽

Ct Angiography ◽

Coronary Ct Angiography ◽

Acute Chest Pain ◽

Coronary Ct

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Faculty Opinions recommendation of Coronary CT angiography versus standard evaluation in acute chest pain.

Faculty Opinions – Post-Publication Peer Review of the Biomedical Literature ◽

10.3410/f.717954171.793459919 ◽

2012 ◽

Author(s):

Mauricio Cohen

Keyword(s):

Chest Pain ◽

Ct Angiography ◽

Coronary Ct Angiography ◽

Acute Chest Pain ◽

Coronary Ct

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Abstract 2004: Usefulness of Coronary CT Angiography in the Early Triage of Patients with Acute Chest Pain

Circulation ◽

10.1161/circ.118.suppl_18.s_655-a ◽

2008 ◽

Vol 118 (suppl_18) ◽

Author(s):

Udo Hoffmann ◽

Fabian Bamberg ◽

Claudia U Chae ◽

Ian S Rogers ◽

Sujith K Seneviratne ◽

...

Keyword(s):

Chest Pain ◽

Hospital Admission ◽

Acute Chest Pain ◽

Coronary Plaque ◽

Discriminatory Power ◽

Coronary Cta ◽

Coronary Syndrome ◽

Coronary Ct ◽

Increased Risk

Background: Early triage of patients with acute chest pain in the emergency department (ED) may be improved by rapid noninvasive assessment of coronary artery disease (CAD) by coronary computed tomography angiography (CTA). We sought to determine the usefulness of coronary CTA for the early triage of patients with acute chest pain but an inconclusive initial ED evaluation. Methods: Single center, double-blinded observational cohort study in the ED of a large tertiary academic hospital enrolling 368 consecutive patients with acute chest pain and inconclusive initial ED evaluation (normal initial troponin and an initial ECG without evidence of myocardial ischemia) who were awaiting hospital admission between May 2005 and May 2007. All patients underwent 64-slice contrast-enhanced coronary CTA prior to hospital admission with caregivers and patients blinded to the results of the examination. Diagnostic accuracy and discriminatory power of coronary CTA findings (coronary plaque and stenosis [>50% luminal narrowing]) for 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 (8%) developed ACS but no MACE occurred during follow-up. Fifty percent (n=183) of the study population had neither plaque nor stenosis, a finding which had 100% negative predictive value (95% confidence interval [CI]: 98 to 100%) for ACS. In adjusted analysis, the extent of coronary plaque and presence of stenosis were associated with an increased risk for ACS (OR: 1.28, 95% CI: 1.14 to 1.43 and OR: 11.69, 95% CI: 4.4 to 31.0; respectively). Coronary CT findings (no CAD, plaque but no stenosis, and stenosis) discriminated patients at low, intermediate, or high risk of ACS (OR: 8.65, 95% CI: 3.69 to 20.26; AUC: 0.91). Conclusion : Half of the patients with acute chest pain and low to intermediate likelihood of ACS have no CAD and may be safely discharged directly from the ED. Coronary CT has excellent discriminatory power in defining patient risk for ACS.

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Abstract 46: Potential of Coronary CT Angiography to Optimize Medical Therapy in Patients Presenting With Acute Chest Pain

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.6.suppl_1.a46 ◽

2013 ◽

Vol 6 (suppl_1) ◽

Author(s):

Amit Pursnani ◽

Christopher L Schlett ◽

Pearl Zakroysky ◽

Parmanand Singh ◽

James L Januzzi ◽

...

Keyword(s):

Emergency Department ◽

Chest Pain ◽

Secondary Prevention ◽

Ct Angiography ◽

Medical Therapy ◽

Coronary Ct Angiography ◽

Acute Chest Pain ◽

Coronary Ct ◽

Prevention Guidelines ◽

Pain Patients

Background: Coronary artery disease (CAD) detected by coronary CT angiography (CCTA) independently predicts cardiovascular events. We assessed the potential of CCTA to tailor aspirin (ASA) and statin medical therapy in acute chest pain patients presenting to the emergency department. Methods: We included all patients from the Rule Out Myocardial Infarction Using Computer Assisted Tomography (ROMICAT) Trial. This prospective double-blinded observational cohort study included patients presenting with chest pain to the emergency department with low-intermediate risk for acute coronary syndrome (ACS). Patients underwent CCTA prior to admission, followed by standard evaluation. Caretakers were blinded to CCTA results. We assessed medical therapy at presentation and discharge, and determined concordance of CAD status by CCTA with medical therapy dictated by standard care. Results: Complete data on medical therapy was available in 358/368 patients (99%), (53±12 years, 61% men) of whom 7 had a contraindication to ASA and 11 to statin. Standard of care included stress testing in 71% of patients. Prescription of ASA and statins increased from admission to discharge (See Figure). At discharge, 33% of patients without CAD were on ASA and 14% were on statin. Conversely, 46% of patients with nonobstructive CAD by CCTA did not receive ASA and 59% did not receive statin at discharge. Only 66% of patients with obstructive CAD were on statin and ASA at discharge. Based on 2011 American College of Cardiology/American Heart Association secondary prevention guidelines, there was discordance between CAD status by CCTA and medical therapy in 51% of patients. Conclusions: CCTA has great potential to optimize adherence to secondary prevention guidelines in chest pain patients presenting to the emergency department.

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