Is there a role for a local inpatient CT coronary angiography service in selected patients with acute coronary syndrome? A cohort analysis of inpatient tertiary centre referrals for invasive coronary angiography

A 32-year-old man with no medical history went into ventricular fibrillation while running at the gym. He was transferred to our tertiary centre post successful resuscitation where admission electrocardiography and echocardiography were unremarkable. The initial cause of cardiac arrest was suspected arrhythmogenic and he was admitted for further investigations including exercise testing, ajmaline challenge, CT coronary angiography (CTCA) and cardiovascular MRI, with the likely outcome of cardioverter-defibrillator implantation. CTCA, however, revealed significant stenosis in the proximal left anterior descending artery as the likely cause for his arrest. Invasive coronary angiography confirmed this and facilitated successful stent implantation, avoiding the need for implantable cardioverter-defibrillator implantation. This case highlights the importance of CTCA, a non-invasive and readily-available test in the investigation of young patients postcardiac arrest, who require active exclusion of coronary artery disease and anomalous coronary anatomy, though they represent a low-risk population group.

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What is the Optimal Rate of Invasive Coronary Angiography After Acute Coronary Syndrome? (ANZACS-QI 22)

Heart Lung and Circulation ◽

10.1016/j.hlc.2019.01.006 ◽

2020 ◽

Vol 29 (2) ◽

pp. 262-271 ◽

Cited By ~ 1

Author(s):

Daniel Chan ◽

Samia Ghazali ◽

Vanessa Selak ◽

Mildred Lee ◽

Tony Scott ◽

...

Keyword(s):

Acute Coronary Syndrome ◽

Coronary Angiography ◽

Invasive Coronary Angiography ◽

Optimal Rate ◽

Coronary Syndrome

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Randomised Controlled Trial of Early CT Coronary Angiography in Patients With Suspected Acute Coronary Syndrome

SSRN Electronic Journal ◽

10.2139/ssrn.3745131 ◽

2020 ◽

Author(s):

Alasdair J. Gray ◽

Carl Roobottom ◽

Jason E Smith ◽

Steve Goodacre ◽

Katherine Oatey ◽

...

Keyword(s):

Acute Coronary Syndrome ◽

Randomised Controlled Trial ◽

Coronary Angiography ◽

Controlled Trial ◽

Ct Coronary Angiography ◽

Coronary Syndrome ◽

Randomised Controlled

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64-Slice CT coronary angiography in patients with non-ST elevation acute coronary syndrome

Heart ◽

10.1136/hrt.2006.112771 ◽

2007 ◽

Vol 93 (11) ◽

pp. 1386-1392 ◽

Cited By ~ 67

Author(s):

W. B Meijboom ◽

N. R Mollet ◽

C. A Van Mieghem ◽

A. C Weustink ◽

F. Pugliese ◽

...

Keyword(s):

Acute Coronary Syndrome ◽

Coronary Angiography ◽

Ct Coronary Angiography ◽

Coronary Syndrome ◽

St Elevation ◽

Elevation Acute Coronary Syndrome

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CT Coronary Angiography in a Case of Acute Coronary Syndrome: Choosing Wisely

Heart Lung and Circulation ◽

10.1016/j.hlc.2017.06.487 ◽

2017 ◽

Vol 26 ◽

pp. S256 ◽

Cited By ~ 1

Author(s):

S. Wakeling ◽

H. Brownstein ◽

A. Al-Kaisey ◽

N. Jones ◽

D. Fernando

Keyword(s):

Acute Coronary Syndrome ◽

Coronary Angiography ◽

Ct Coronary Angiography ◽

Choosing Wisely ◽

Coronary Syndrome

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Usefulness of troponin in selecting patients for invasive coronary angiography after cardiac surgery

European Heart Journal ◽

10.1093/ehjci/ehaa946.1667 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

H Omran ◽

M.A Deutsch ◽

E Groezinger ◽

A Renner ◽

J Neumann ◽

...

Keyword(s):

Acute Coronary Syndrome ◽

Cardiac Surgery ◽

Coronary Angiography ◽

Predictive Value ◽

Primary Outcome ◽

Invasive Coronary Angiography ◽

High Sensitivity ◽

Exclusion Criteria ◽

Coronary Syndrome ◽

Cabg Patients

Abstract Background Great uncertainty exists about the indication for invasive coronary angiography (ICA) in patients with suspected acute coronary syndrome following cardiac surgery. Aim The aim of this study was to define clinical criteria that best identify patients who benefit from ICA after cardiac surgery. Methods We performed a retrospective analysis of all patients who underwent cardiac surgery between January 2009 and May 2019 at our center. Exclusion criteria included pediatric patients as well as pacemaker, TAVR and LVAD implantation and heart transplantation procedures. The primary outcome was usefulness of ICA as defined by consequent PCI or re-operation due to ICA findings. ECG changes (ST-elevations) and high-sensitivity Troponin I (hsTrop I) were analyzed. Results 48,136 patients were screened and after applying exclusion criteria 29,359 patients were finally included in the analysis (mean age 67.8±11.0 years, 31.1% females, Euroscore II 5.14±8.9%). A total of 1,171 patients (4%) underwent post-op ICA. The primary outcome occurred in 440 patients (1.5%) of which 290 underwent consequent PCI and 214 underwent consequent re-operation. Baseline characteristics are shown in table 1. Unadjusted analyses did not identify significant differences in the level of cardiac biomarkers between useful-ICA and unuseful-ICA groups. In multivariate regression analysis, only ST-elevation on ECG predicted the primary outcome (OR 1.33, 95% CI 1.003–1.76). Dichotomizing hsTrop I concentrations by applying the guideline-specified cut-off (>70x URL) resulted in correct classification of useful-ICA patients in 95.7%. However, the false-positive rate was also extremely high (83.6%) with a positive predictive value (PPV) of 1.6% and a negative predictive value (NPV) of 99.6% (accuracy 17.5%). Using area under the curve (ROC) analysis following optimal cut-off values for hsTrop I were identified: in CABG patients a cut-off value of >650x URL (corresponding absolute value 17000 ng/L) was defined with a corresponding sensitivity of 83.3%, specificity of 83.6%, PPV of 8.9% and NPV of 99.6% (accuracy 83.6%). In non-CABG patients (i.e. valve or aortic procedures), the cut-off was about twice as high as that for CABG patients (1,350x URL or 35,000 ng/L) with a corresponding sensitivity of 84.1%, specificity of 89.2%, PPV of 5.9% and NPV of 99.9% (accuracy 89.1%). Conclusion Our study demonstrates that currently recommended cut-off concentrations of high-sensitivity troponin are not useful for guiding clinical decision-making in patients with suspected acute coronary syndrome following cardiac surgery, while substantially higher cut-off values might be useful. Those cut-off values critically depend on the type of cardiac surgery performed (CABG vs. non-CABG). Troponin_Curves post-op Funding Acknowledgement Type of funding source: None

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Importance of Risk Assessment in Timing of Invasive Coronary Evaluation and Treatment of Patients With Non–ST‐Segment–Elevation Acute Coronary Syndrome: Insights From the VERDICT Trial

Journal of the American Heart Association ◽

10.1161/jaha.121.022333 ◽

2021 ◽

Author(s):

Jawad H. Butt ◽

Klaus F. Kofoed ◽

Henning Kelbæk ◽

Peter R. Hansen ◽

Christian Torp‐Pedersen ◽

...

Keyword(s):

Acute Coronary Syndrome ◽

Coronary Angiography ◽

Invasive Coronary Angiography ◽

Invasive Strategy ◽

St Segment Elevation ◽

Risk Of Death ◽

Coronary Syndrome ◽

St Segment ◽

Elevation Acute Coronary Syndrome ◽

Grace Score

Background The optimal timing of invasive examination and treatment of high‐risk patients with non–ST‐segment–elevation acute coronary syndrome has not been established. We investigated the efficacy of early invasive coronary angiography compared with standard‐care invasive coronary angiography on the risk of all‐cause mortality according to the GRACE (Global Registry of Acute Coronary Events) risk score in a predefined subgroup analysis of the VERDICT (Very Early Versus Deferred Invasive Evaluation Using Computerized Tomography) trial. Methods and Results Patients with clinical suspicion of non–ST‐segment–elevation acute coronary syndrome with ECG changes indicating new ischemia and/or elevated troponin, in whom invasive coronary angiography was clinically indicated and deemed logistically feasible within 12 hours, were eligible for inclusion. Patients were randomized 1:1 to an early (≤12 hours) or standard (48–72 hours) invasive strategy. The primary outcome of the present study was all‐cause mortality. Of 2147 patients randomized in the VERDICT trial, 2092 patients had an available GRACE risk score. Of these, 1021 (48.8%) patients had a GRACE score >140. During a median follow‐up of 4.1 years, 192 (18.8%) and 54 (5.0%) patients died in the high and low GRACE score groups, respectively. The risk of death with the early invasive strategy was increased in patients with a GRACE score ≤140 (hazard ratio [HR], 2.04 [95% CI, 1.16–3.59]), whereas there was a trend toward a decreased risk of death with the early invasive strategy in patients with a GRACE score >140 (HR, 0.83 [95% CI, 0.63–1.10]) ( P interaction =0.006). Conclusions In patients with non–ST‐segment–elevation acute coronary syndrome, we found a significant interaction between timing of invasive coronary angiography and GRACE score on the risk of death. Randomized clinical trials are warranted to establish the efficacy and safety among high‐risk and low‐risk patients with non–ST‐segment–elevation acute coronary syndrome. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02061891.

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Silent brain injury following coronary angiography and revascularization in acute coronary syndrome: another reason to choose patients right

European Heart Journal Acute Cardiovascular Care ◽

10.1093/ehjacc/zuab020.109 ◽

2021 ◽

Vol 10 (Supplement_1) ◽

Author(s):

L Malinova ◽

S Tolstov ◽

T Lipatova ◽

T Denisova

Keyword(s):

Acute Coronary Syndrome ◽

Brain Injury ◽

Coronary Angiography ◽

Invasive Coronary Angiography ◽

Coronary Intervention ◽

Ischemic Brain Injury ◽

Ischemic Brain ◽

Serial Measurement ◽

Coronary Syndrome ◽

Increased Risk

Abstract Funding Acknowledgements Type of funding sources: None. Invasive coronary angiography (CAG) and revascularization remain the cornerstone of acute coronary syndrome (ACS) treatment. However silent brain injury (SBI) has been previously reported as a non-rare adverse event following coronary intervention. Several studies report serum NR2 antibodies (NR2AB) as a sensitive biomarker of ischemic brain injury suitable for express SBI diagnostics. Recently limited data are available regarding SBI per se in ACS. The relationship between NR2AB and chosen ACS treatment strategy is unclear. The purpose of the study: to evaluate the incidence and predictors of SBI after CAG and percutaneous coronary intervention in patients with ACS by serial measurement of serum NR2AB levels. Materials and methods. We perform local, open, continuous, stratified study involving patients underwent CAG with / without further coronary intervention due to recent ACS (n = 19) and ACS within 30 days (maximum) before recent admission (group of compare, n = 25). Serum NR2 antibodies concentration measured serially (before and no longer that 6 hours after the procedure) was used as SBI marker. Results. Endovascular coronary intervention in 15.9% was accompanied by NR2AB increase: the majority of NR2AB increase cases were observed in the group of compare (31.6% vs 5.5%). In those patients with prior ACS there was an increased risk of NR2AB level rise following PCI, that is, silent ischemic brain damage: HR 0.219 CI 0.171; 0.280, p = 0.049. Patients who underwent stenting of the coronary arteries were characterized by a more pronounced significant NR2 antibodies decrease after the procedure: -10.37 (-23.25; -7.65) vs -5.03 (-9.41; -1.79) % in ACS (p = 0.046) and -10.17 (-10.79; -10.20) vs -6.06 (-11.01; 4.68)% in the group of compare (p = 0.044), respectively. Conclusion. Coronary angiography and intervention in ACS is associated with a certain risk of silent ischemic brain injury (as has been assessed by NR2AB dynamics), increased in those cases where procedure was limited to CAG only. According to the results of the study, it seems reasonable to perform a preprocedure assessment of revascularization possibility to minimize risks of the possibility of ischemic brain injury.

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