Usefulness of 64-Slice Multidetector Computed Tomography in Diagnostic Triage of Patients With Chest Pain and Negative or Nondiagnostic Exercise Treadmill Test Result

doi:10.1016/j.amjcard.2006.10.059

The American Journal of Cardiology

Volume 99, Issue 7, 1 April 2007, Pages 925-929

https://doi.org/10.1016/j.amjcard.2006.10.059 Get rights and content

The usefulness of 64-slice multidetector coronary computed tomography (MDCT) in a diagnostic triage of 100 consecutive patients (age 55.8 ± 11.6 years; 57% men) with chest pain suspected to be ischemic in origin and a negative or nondiagnostic exercise treadmill test (ETT) result was examined. None of the patients had previously known coronary artery disease (CAD). MDCT showed obstructive (≥50%) CAD in 29 patients; 13 of 59 patients (22%) with a negative and 16 of 41 patients (39%) with a nondiagnostic ETT result. High-risk (left main and/or 3-vessel) CAD was present in 3.3% of patients with a negative and 4.9% with a nondiagnostic ETT result. The 29 patients with obstructive CAD on MDCT had a higher mean Agatston calcium score (221 ± 402 vs 40 ± 77 U, p <0.001). Invasive coronary angiography confirmed MDCT findings in 26 of 29 patients (positive predictive value 90%) and 45 of 54 stenotic segments (83%) in a per-segment analysis. For the 71 patients without obstructive CAD on MDCT, clinically driven invasive angiography detected CAD in 1 of 15 patients (1 false-negative MDCT result) and 2 of another 5 patients who were referred for invasive angiography later during a 12-month follow-up period. In the remaining 51 patients, MDCT findings effectively allowed exclusion of obstructive CAD, and there were no major adverse clinical events during follow-up. In conclusion, in patients with chest pain possibly ischemic in origin, no previously known CAD, and a negative or nondiagnostic ETT result, contrast-enhanced 64-slice MDCT scanning was a useful tool to provide direct noninvasive coronary angiography and rapidly advance diagnostic triage.

Section snippets

Patient sample

The study was a retrospective analysis of the findings in 103 consecutive patients evaluated for chest pain symptoms who had a negative or nondiagnostic ETT result and who were referred for MDCT during a 10-week period by their treating physician. Exclusion criteria were cardiac arrhythmias, such as atrial fibrillation or other tachyarrhythmias, abnormal renal function (serum creatinine >1.3 mg/dl), inability to perform a short 10- to 15-second breath-hold, or known allergy to radiographic

Multidetector coronary computed tomographic image quality

MDCT scans of diagnostic quality were obtained in 100 of 103 patients (97%). Scans with significant motion artifacts in 2 patients and with heavy calcifications in another were excluded from further analysis. Thus, overall image quality was good in 83 patients, moderate in 17, and severely suboptimal in 3 (excluded). MDCT results are presented on a per-patient basis and a per-segment analysis in comparisons with invasive angiography. In the segmental analysis, 94% of coronary segments were

Discussion

Obstructive CAD was diagnosed using MDCT in 22% of patients with a negative ETT result and excluded obstructive CAD in 61% of patients with a nondiagnostic ETT result. In symptomatic patients with negative or nondiagnostic ETT results, the prevalence of obstructive disease generally is low to moderate. In this population, MDCT would be expected to have a high negative predictive value and may be superior to physiologic testing. In patients referred for invasive angiography despite a negative

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ACR Appropriateness Criteria® Chest Pain-Possible Acute Coronary Syndrome
2020, Journal of the American College of Radiology
Citation Excerpt :
In stable patients with suggested ACS at low or intermediate risk of adverse events, a noninvasive coronary imaging test (ie, coronary CTA [CCTA]) is a proven alternative to stress testing or selective coronary angiography [19,59,60]. CCTA has a very high negative predictive value for the detection of coronary atherosclerosis with or without significant stenosis and is an alternative to stress imaging in the emergency department and inpatient settings in patients at low to intermediate risk for CAD [59,61-64]. Large randomized controlled trials (eg, CT-STAT, ROMICAT I and II, ACRIN-PA, PROSPECT, CT-COMPARE, CATCH, and CATCH-2) have amply established the high negative predictive value (eg, safe discharge) and good prognosis of a negative CCTA in low- to intermediate-risk patients suspected of ACS when compared with standard pathways that predominantly involve stress nuclear MPI [65-72].
Chest pain is a frequent cause for emergency department visits and inpatient evaluation, with particular concern for acute coronary syndrome as an etiology, since cardiovascular disease is the leading cause of death in the United States. Although history-based, electrocardiographic, and laboratory evaluations have shown promise in identifying coronary artery disease, early accurate diagnosis is paramount and there is an important role for imaging examinations to determine the presence and extent of anatomic coronary abnormality and ischemic physiology, to guide management with regard to optimal medical therapy or revascularization, and ultimately to thereby improve patient outcomes. A summary of the various methods for initial imaging evaluation of suspected acute coronary syndrome is outlined in this document.
The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
Coronary computed tomography and triple rule out CT in patients with acute chest pain and an intermediate cardiac risk profile. Part 1: Impact on patient management
2013, European Journal of Radiology
Citation Excerpt :
A large number of studies including meta-analysis have demonstrated a high negative predictive value for coronary CTA and TRO-CTA for the exclusion of significant coronary artery stenosis [10,15–20]. Moreover, a limited number of studies have demonstrated [14,15,17] that coronary CTA may improve management and reduce overall costs of patients with acute chest pain and a low pretest likelihood of ACS [7,9,21,22]. The radiation dose of TRO-CTA observed in our study was approximately 30% higher when compared to a standard coronary CTA protocol.
To evaluate the impact of coronary CT angiography (coronary CTA) or “triple-rule-out” CT angiography (TRO-CTA) on patient management in the work-up of patients with acute chest pain and an intermediate cardiac risk profile.
100 patients with acute chest pain and an intermediate cardiac risk for acute coronary syndrome (ACS) underwent coronary CTA or TRO-CTA for the evaluation of chest pain. Patients with a high and low cardiac risk profile were not included in this study. All patients with significant coronary stenosis >50% on coronary CTA underwent invasive coronary catheterization (ICC). Important other pathological findings were recorded. All patients had a 90-day follow-up period for major adverse cardiac events (MACE).
Based on a negative coronary CTA 60 of 100 patients were discharged on the same day. None of the discharged patients showed MACE during the 90-day follow-up. Coronary CTA revealed a coronary stenosis >50% in 19 of 100 patients. ICC confirmed significant coronary stenosis in 17/19 patients. Among the 17 true positive patients, 9 underwent percutaneous coronary intervention with stent implantation, 7 were received intensified medical therapy, and 1 patient underwent coronary artery bypass surgery.
A TRO-CTA protocol was performed in 36/100 patients due to elevated d-dimer levels. Pulmonary embolism was present in 5 patients, pleural effusion of unknown etiology in 3 patients, severe right ventricular dysfunction with pericardial effusion in 1 patient, and an incidental bronchial carcinoma was diagnosed in 1 patient.
Coronary CTA and TRO-CTA allow a rapid and safe discharge in the majority of patients presenting with acute chest pain and an intermediate risk for ACS while at the same time identifies those with significant coronary artery stenosis.
ACR appropriateness Criteria® on chest pain, suggestive of acute coronary syndrome
2011, Journal of the American College of Radiology
Acute chest pain suggestive of acute coronary syndrome is a frequent complaint in the emergency department. Acute coronary syndromes include myocardial infarction and unstable angina. Being able to establish the diagnosis rapidly and accurately may be lifesaving. A cardiac workup is indicated in this subset of patients in the acute setting, even if there are no ischemic changes on electrocardiography. If the clinical examination and initial cardiac workup suggest that a patient is having myocardial ischemia, the patient will usually be urgently referred for invasive coronary angiography and revascularization. In stable patients without evidence of ST elevation and ongoing myocardial ischemia, an initially conservative approach is sometimes considered. Cardiac risk stratification of this subgroup of patients who are at low and intermediate risk for coronary artery disease is recommended before discharge, and imaging is necessary to exclude ischemia as an etiology. Noninvasive cardiac imaging modalities include chest radiography, single photon-emission CT myocardial perfusion imaging, echocardiography, multidetector CT, PET, and MRI. Noncardiac etiologies of chest pain include aortic dissection, aortic aneurysm, pulmonary embolism, pericardial disease, and lung parenchymal disease. Noninvasive cardiac imaging in patients who are at low and intermediate risk for coronary artery disease may improve confidence regarding the safety of discharge from the emergency department. In addition to risk stratification, noncoronary etiologies for chest pain can be established with imaging.
Clinical management and short-term cost - 64-slice MDCT vs. myocardial perfusion scintigraphy
2010, International Journal of Cardiology
There are currently no published studies of the impact of CT coronary angiography (CTA) on patient management or cost when compared with other established imaging techniques. We assessed the short term investigation and treatment costs of CTA compared with myocardial perfusion scintigraphy (MPS) using real clinical scenarios. Clinical information with either their CTA or MPS results were presented to 20 cardiologists in a random order. They decided further investigations and treatment required based on these data. Short term cost was calculated for each imaging strategy. Whilst the total number of further investigations requested did not differ between groups patients undergoing CTA were more likely to be referred for invasive coronary angiography, receive aspirin, statins, ACE inhibitors, β-blockers or clopidogrel. Overall cost and investigation costs were similar between CTA and MPS; however treatment costs were higher with CTA. There are significant differences in further clinical management when using CTA compared with MPS, in particular with greater use of secondary preventative medication.
Multi-detector computerized tomography angiography for evaluation of acute chest pain - A meta analysis and systematic review of literature
2010, International Journal of Cardiology
Evaluation of pain localized to the chest in the emergency room is, challenging, time-consuming, costly, and often inconclusive. Available research, though limited, suggests a role for MDCTA in the evaluation of patients with acute chest pain of low to intermediate risk, for identifying and excluding ACSs during the initial emergency department evaluation. Accordingly, our aim was to conduct a meta-analysis to assess the diagnostic accuracy of MDCTA in this setting.
We included all studies that compared MDCTA with either coronary angiography or standard of care for early and accurate triage of patients presenting with acute chest pain. Published studies were identified by searches of the Pubmed, Ovid and Google scholar databases as well as hand searches of selected references. Data were extracted independently by two reviewers. Included studies were evaluated for heterogeneity. Meta-analysis was performed at patient level using a random-effects model.
16 studies totaling 1119 patients were included in the current meta-analysis: one randomized trial, one retrospective analysis and fourteen prospective cohort studies. Pooled DOR was 190.80 (95%CI, 102.94–353.65). The pooled sensitivity and specificity were 0.96 (95%CI, 0.93–0.98) and 0.92(95%CI, 0.89–0.94) respectively. The pooled NLR and PLR were 0.09 (95%CI, 0.06–0.14) and 10.12 (95%CI, 6.73–15.22).
MDCTA has an excellent diagnostic accuracy in detection of significant coronary artery stenosis in patients with acute chest pain. This diagnostic accuracy of MDCTA has a potential for rapid triage of patients in the ED, with acute chest pain of low to intermediate risk of acute coronary syndrome, to rule out significant epicardial stenosis as the etiology of chest pain.
Comparison of Usefulness of Exercise Testing Versus Coronary Computed Tomographic Angiography for Evaluation of Patients Suspected of Having Coronary Artery Disease
2010, American Journal of Cardiology
Citation Excerpt :
Regardless of the exercise test outcome, CTA revealed a similar proportion of patients with apparently normal coronary arteries, with nonsignificant, and significant CAD. In concordance with the results by Rubinshtein et al,23 a non-negligible proportion of patients with negative exercise test results had significant CAD in the present investigation. Furthermore, a large proportion of patients with negative exercise test results had nonsignificant CAD (Figure 2).
In patients suspected of having coronary artery disease (CAD), we compared the diagnostic sensitivity and specificity of exercise testing using ST-segment changes alone and ST-segment changes, angina pectoris, and hemodynamic variables compared to coronary computed tomographic angiography (CTA). Quantitative invasive coronary angiography was the reference method (>50% coronary lumen reduction). A positive exercise test was defined as the development of significant ST-segment changes (≥1 mV measured 80 ms from the J-point), and the occurrence of one or more of the following criteria: ST-segment changes ≥1 mV measured 80 ms from the J-point, angina pectoris, ventricular arrhythmia (the occurrence of ≥3 premature ventricular beats), and ≥20 mm Hg decrease in systolic blood pressure during the test. Positive results on CTA were defined as a coronary lumen reduction of ≥50%. In 100 patients (61 ± 9 years old, 50% men, and 29% prevalence of significant CAD), the diagnostic sensitivity and specificity of exercise testing using ST-segment changes was 45% (95% confidence interval 53% to 87%) and 63% (95% confidence interval 61% to 84%), respectively. However, the inclusion of all test variables yielded a sensitivity of 72% (95% confidence interval 53% to 87%) and a specificity of 37% (95% confidence interval 26% to 49%). The diagnostic sensitivity of 97% (95% confidence interval 82% to 100%) and specificity of 80% (95% confidence interval 69% to 89%) for CTA, however, were superior to any of the exercise test analysis strategies. In conclusion, in patients suspected of having CAD, the diagnostic sensitivity of exercise testing significantly improves if all test variables are included compared to using ST-segment changes exclusively. Furthermore, the superior diagnostic performance of CTA for the detection and exclusion of significant CAD might favor CTA as the first-line diagnostic test in patients suspected of having CAD.

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Coronary artery diseaseUsefulness of 64-Slice Multidetector Computed Tomography in Diagnostic Triage of Patients With Chest Pain and Negative or Nondiagnostic Exercise Treadmill Test Result

Section snippets

Patient sample

Multidetector coronary computed tomographic image quality

Discussion

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Am J Cardiol

Am J Cardiol

Am J Cardiol

Eur J Radiol

Exercise standards for testing and training: a statement for healthcare professionals from the American Heart Association

Circulation

Coronary artery disease
Usefulness of 64-Slice Multidetector Computed Tomography in Diagnostic Triage of Patients With Chest Pain and Negative or Nondiagnostic Exercise Treadmill Test Result