Prognostic Value of CT Angiography for Major Adverse Cardiac Events in Patients With Acute Chest Pain From the Emergency Department

Abstract

OBJECTIVES The aim of this study was to determine the 2-year prognostic value of cardiac computed tomography (CT) for predicting major adverse cardiac events (MACE) in patients presenting to the emergency department (ED) with acute chest pain. BACKGROUND CT has high potential for early triage of acute chest pain patients. However, there is a paucity of data regarding the prognostic value of CT in this ED cohort. METHODS We followed 368 patients from the ROMICAT (Rule Out Myocardial Infarction Using Computer Assisted Tomography) trial (age 53 ± 12 years; 61% male) who presented to the ED with acute chest pain, negative initial troponin, and a nonischemic electrocardiogram for 2 years. Contrast-enhanced 64-slice CT was obtained during index hospitalization, and caregivers and patients remained blinded to the results. CT was assessed for the presence of plaque, stenosis (>50% luminal narrowing), and left ventricular regional wall motion abnormalities (RWMA). The primary endpoint was MACE, defined as composite cardiac death, nonfatal myocardial infarction, or coronary revascularization. RESULTS Follow-up was completed in 333 patients (90.5%) with a median follow-up period of 23 months. At the end of the follow-up period, 25 patients (6.8%) experienced 35 MACE (no cardiac deaths, 12 myocardial infarctions, and 23 revascularizations). Cumulative probability of 2-year MACE increased across CT strata for coronary artery disease (CAD) (no CAD 0%; nonobstructive CAD 4.6%; obstructive CAD 30.3%; log-rank p < 0.0001) and across combined CT strata for CAD and RWMA (no stenosis or RWMA 0.9%; 1 feature—either RWMA [15.0%] or stenosis [10.1%], both stenosis and RWMA 62.4%; log-rank p < 0.0001). The c statistic for predicting MACE was 0.61 for clinical Thrombolysis In Myocardial Infarction risk score and improved to 0.84 by adding CT CAD data and improved further to 0.91 by adding RWMA (both p < 0.0001). CONCLUSIONS CT coronary and functional features predict MACE and have incremental prognostic value beyond clinical risk score in ED patients with acute chest pain. The absence of CAD on CT provides a 2-year MACE-free warranty period, whereas coronary stenosis with RWMA is associated with the highest risk of MACE.

Chest pain: coronary CT in the ER

“…In contrast, the presence of severe CAD is associated with the worst outcome (30.3% cumulative event rate), whereas those with mild or moderate CAD (#50% stenosis) have intermediate outcomes (4.6% cumulative event rate). 81 Interestingly, major adverse cardiac events developed in most of the patients (80%) during the first 30 days after presentation to the ED, suggesting that the strength of cardiac CT is in its diagnostic ability during the acute phase. Furthermore, evaluation of LV function at the index CT examination was shown to provide incremental prognostic value for long-term follow-up.…”

“…[81][82][83] The true impact can only be determined in prospective observational studies such as the ROMICAT I trial, given the blinded nature of the results of cardiac CT among both caregivers and patients. The ROMICAT trial indicated that the absence of CAD on CT provides a 2-year "warranty period" free of major cardiovascular events.…”

“…Furthermore, evaluation of LV function at the index CT examination was shown to provide incremental prognostic value for long-term follow-up. 81 Current recommendations and guidelines of cardiac CT in the emergency department Since 2010 when cardiac CT received a rating of "appropriate" in patients at low-to-intermediate risk presenting with ACP at the ED, 84 several guidelines by the ESC and American Heart Association/American College of Cardiology (AHA/ACC) as well as by other societies and organizations have discussed in recent years this application of cardiac CT.…”

Cardiac Imaging Modalities in the Diagnosis of Coronary Artery Disease

“…Studies based on single center and multicenter clinical trials have shown that coronary CT angiography provides incremental prognostic value over clinical risk analysis in predicting major adverse cardiac events with absence of CAD leading to event free survival period, while presence of plaques associated with increased risk of cardiac events [15][16][17][18][19].…”

Escore de cálcio para avaliar dor torácica na sala de emergência

“…Therefore, it has recently been used for CAD diagnosis, mainly in symptomatic patients with intermediate pretest probability of disease. The ROMICAT trial showed that negative CCTA results for the evaluation of acute chest pain are associated with a good 2-year prognosis, with a cumulative probability of 2-year major adverse cardiac events increased across CCTA strata for CAD (no CAD 0%; non obstructive CAD 4.6%; CAD with obstruction > 50% 30.3%) 2 . Adding CCTA to the current emergency department risk stratification of acute chest pain was more cost-effective when compared to standard care because of reduced recurrence and rehospitalization 3 .…”