Background-Noninvasive assessment of coronary atherosclerotic plaque and significant stenosis by coronary multidetector computed tomography (MDCT) may improve early and accurate triage of patients presenting with acute chest pain to the emergency department. Methods and Results-We conducted a blinded, prospective study in patients presenting with acute chest pain to the emergency department between May and July 2005 who were admitted to the hospital to rule out acute coronary syndrome (ACS) with no ischemic ECG changes and negative initial biomarkers. Contrast-enhanced 64-slice MDCT coronary angiography was performed immediately before admission, and data sets were evaluated for the presence of coronary atherosclerotic plaque and significant coronary artery stenosis. All providers were blinded to MDCT results.
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.
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