Diagnostic performance of coronary calcifications on CT to rule out acute coronary syndrome in the emergency department.
Humans
Acute Coronary Syndrome
/ diagnostic imaging
Female
Male
Emergency Service, Hospital
Retrospective Studies
Middle Aged
Electrocardiography
Aged
Tomography, X-Ray Computed
Troponin
/ blood
Chest Pain
/ etiology
France
Sensitivity and Specificity
Calcinosis
/ diagnostic imaging
Vascular Calcification
/ diagnostic imaging
Acute coronary syndrome
Chest pain
Coronary artery calcifications
Emergency department
Ultra low dose chest Computed Tomography
Journal
BMC emergency medicine
ISSN: 1471-227X
Titre abrégé: BMC Emerg Med
Pays: England
ID NLM: 100968543
Informations de publication
Date de publication:
12 Jul 2024
12 Jul 2024
Historique:
received:
03
04
2024
accepted:
04
07
2024
medline:
13
7
2024
pubmed:
13
7
2024
entrez:
12
7
2024
Statut:
epublish
Résumé
At present, the diagnosis of acute coronary syndrome (ACS) can be made by emergency physicians using the usual complementary tests, since the current troponin and electrocardiogram (ECG) protocols have been extensively tested for their safety. However, the detection of coronary calcifications on CT associated with coronary obstruction may be of interest for the diagnostic strategy in the emergency department (ED). The aim of this study was to evaluate a strategy combining a non-ischemic ECG with an initial normal troponin assay and the diagnostic accuracy of chest CT in detecting coronary calcifications to rule out the presence of an acute coronary event in patients presenting with chest pain in the ED. This was a retrospective, single-center study carried out in an ED in France and included all patients over 18 years of age presenting with chest pain between 1 June 2021 and 31 December 2021 with a non-ischemic ECG and a negative first troponin assay. The primary endpoint was the diagnostic performance of the combing strategy in ruling out ACS. The secondary endpoints were the sensitivity and specificity of calcifications in acute coronary syndrome, comparison with the diagnostic performance of a second troponin assay and the rate of reconsultation, rehospitalisation and investigations within 2 months of the ED. Of the 280 patients included, 141 didn't have calcifications. A total of 14 events were found with a negative predictive value for the combining strategy of 99.8% [95%CI: 98.2 - 100]. Sensitivity and specificity were 98.4% [95%CI: 83.8 - 100] and 53% [95%CI: 47 - 58.9], respectively. Among patients with no calcification, 8.2% were admitted to hospital and none suffered an acute coronary event. A total of 36 patients (12.8%) consulted a doctor within 2 months, with 23 investigations, all of which were negative in the non-calcification group. A strategy combining the detection of coronary calcifications on chest CT in patients with a non-ischemic ECG and a single troponin assay is effective to rule out ACS in the ED, and may perform better then ECG and troponin alone.
Sections du résumé
BACKGROUND
BACKGROUND
At present, the diagnosis of acute coronary syndrome (ACS) can be made by emergency physicians using the usual complementary tests, since the current troponin and electrocardiogram (ECG) protocols have been extensively tested for their safety. However, the detection of coronary calcifications on CT associated with coronary obstruction may be of interest for the diagnostic strategy in the emergency department (ED). The aim of this study was to evaluate a strategy combining a non-ischemic ECG with an initial normal troponin assay and the diagnostic accuracy of chest CT in detecting coronary calcifications to rule out the presence of an acute coronary event in patients presenting with chest pain in the ED.
METHODS
METHODS
This was a retrospective, single-center study carried out in an ED in France and included all patients over 18 years of age presenting with chest pain between 1 June 2021 and 31 December 2021 with a non-ischemic ECG and a negative first troponin assay. The primary endpoint was the diagnostic performance of the combing strategy in ruling out ACS. The secondary endpoints were the sensitivity and specificity of calcifications in acute coronary syndrome, comparison with the diagnostic performance of a second troponin assay and the rate of reconsultation, rehospitalisation and investigations within 2 months of the ED.
RESULTS
RESULTS
Of the 280 patients included, 141 didn't have calcifications. A total of 14 events were found with a negative predictive value for the combining strategy of 99.8% [95%CI: 98.2 - 100]. Sensitivity and specificity were 98.4% [95%CI: 83.8 - 100] and 53% [95%CI: 47 - 58.9], respectively. Among patients with no calcification, 8.2% were admitted to hospital and none suffered an acute coronary event. A total of 36 patients (12.8%) consulted a doctor within 2 months, with 23 investigations, all of which were negative in the non-calcification group.
CONCLUSIONS
CONCLUSIONS
A strategy combining the detection of coronary calcifications on chest CT in patients with a non-ischemic ECG and a single troponin assay is effective to rule out ACS in the ED, and may perform better then ECG and troponin alone.
Identifiants
pubmed: 38997628
doi: 10.1186/s12873-024-01038-2
pii: 10.1186/s12873-024-01038-2
doi:
Substances chimiques
Troponin
0
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
116Informations de copyright
© 2024. The Author(s).
Références
French Parliamentary Committee of Inquiry: Hospitals, moving beyond emergencies. 2022. Report No.: 587. Available online https://www.senat.fr/rap/r21-587-1/r21-587-1.html Accessed on 15–08–2023.
Key figures for emergencies 2022. Federation of French Regional Emergency Observatories, 2022. Available online https://fedoru.fr/chiffres-cles-urgences-2022 Accessed on 02–08–2023.
Morley C, Unwin M, Peterson GM, Stankovich J, Kinsman L. Emergency department crowding: a systematic review of causes, consequences and solutions. PLoS One. 2018;13:e0203316.
doi: 10.1371/journal.pone.0203316
pubmed: 30161242
pmcid: 6117060
Warnant A, Moumneh T, Roy PM, Penaloza A. Chest pain in emergency departments: appropriate use of diagnostic scores. Ann Fr Méd Urgence. 2019;10:89–93.
doi: 10.3166/afmu-2019-0154
Fanaroff AC, Rymer JA, Goldstein SA, Simel DL, Newby LK. Does This patient with chest pain have acute coronary syndrome? the rational clinical examination systematic review. JAMA. 2015;314:1955–65.
doi: 10.1001/jama.2015.12735
pubmed: 26547467
Myocardial infarction - Inserm, science for Helath. Inserm, s. d. https://www.inserm.fr/dossier/infarctus-myocarde/ Accessed on 03–08–2023.
Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Jüni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, RubiniGimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B, ESC Scientific Document Group. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J. 2023;44:3720–826.
doi: 10.1093/eurheartj/ehad191
pubmed: 37622654
Haberl R, Becker A, Leber A, Knez A, Becker C, Lang C, et al. Correlation of coronary calcification and angiographically documented stenoses in patients with suspected coronary artery disease: results of 1,764 patients. J Am Coll Cardiol. 2001;37:451–7.
doi: 10.1016/S0735-1097(00)01119-0
pubmed: 11216962
Sarwar A, Shaw LJ, Shapiro MD, Blankstein R, Hoffmann U, Cury RC, et al. Diagnostic and prognostic value of absence of coronary artery calcification. JACC Cardiovasc Imaging. 2009;2:675–88.
doi: 10.1016/j.jcmg.2008.12.031
pubmed: 19520336
Chaikriangkrai K, PalamanerSubashShantha G, Jhun HY, Ungprasert P, Sigurdsson G, Nabi F, et al. Prognostic value of coronary artery calcium score in acute chest pain patients without known coronary artery disease: systematic review and meta-analysis. Ann Emerg Med. 2016;68:659–70.
doi: 10.1016/j.annemergmed.2016.07.020
pubmed: 27765299
Grandhi GR, Mszar R, Cainzos-Achirica M, Rajan T, Latif MA, Bittencourt MS, et al. Coronary calcium to rule out obstructive coronary artery disease in patients with acute chest pain. JACC Cardiovasc Imaging. 2022;15:271–80.
doi: 10.1016/j.jcmg.2021.06.027
pubmed: 34656462
Cury RC, Feuchtner GM, Batlle JC, Peña CS, Janowitz W, Katzen BT, Ziffer JA. Triage of patients presenting with chest pain to the emergency department: implementation of coronary CT angiography in a large urban health care system. AJR Am J Roentgenol. 2013;200:57–65.
doi: 10.2214/AJR.12.8808
pubmed: 23255742
Blair KJ, Allison MA, Morgan C, Wassel CL, Rifkin DE, Wright CM, et al. Comparison of Ordinal vs. Agatston Coronary Calcification Scoring for Cardiovascular Disease Mortality in Community-Living Individuals. Int J Cardiovasc Imaging. 2014;30:813–8.
doi: 10.1007/s10554-014-0392-1
pubmed: 24610090
pmcid: 4009350
Htwe Y, Cham MD, Henschke CI, Hecht H, Shemesh J, Liang M, et al. Coronary artery calcification on low-dose computed tomography: comparison of Agatston and Ordinal Scores. Clin Imaging. 2015;39:799–802.
doi: 10.1016/j.clinimag.2015.04.006
pubmed: 26068098
Azour L, Kadoch MA, Ward TJ, Eber CD, Jacobi AH. Estimation of cardiovascular risk on routine chest CT: Ordinal coronary artery calcium scoring as an accurate predictor of Agatston score ranges. J Cardiovasc Comput Tomogr. 2017;11:8–15.
doi: 10.1016/j.jcct.2016.10.001
pubmed: 27743881
Litt HI, Gatsonis C, Snyder B, Singh H, Miller CD, Entrikin DW, Leaming JM, Gavin LJ, Pacella CB, Hollander JE. CT angiography for safe discharge of patients with possible acute coronary syndromes. N Engl J Med. 2012;366:1393–403.
doi: 10.1056/NEJMoa1201163
pubmed: 22449295
Hoffmann U, Truong QA, Schoenfeld DA, Chou ET, Woodard PK, Nagurney JT, Pope JH, Hauser TH, White CS, Weiner SG, Kalanjian S, Mullins ME, Mikati I, Peacock WF, Zakroysky P, Hayden D, Goehler A, Lee H, Gazelle GS, Wiviott SD, Fleg JL, Udelson JE, ROMICAT-II Investigators. Coronary CT angiography versus standard evaluation in acute chest pain. N Engl J Med. 2012;367:299–308.
doi: 10.1056/NEJMoa1201161
pubmed: 22830462
pmcid: 3662217
Nakahara T, Dweck MR, Narula N, Pisapia D, Narula J, Strauss HW. Coronary artery calcification: from mechanism to molecular imaging. JACC Cardiovasc Imaging. 2017;10:582–93.
doi: 10.1016/j.jcmg.2017.03.005
pubmed: 28473100
Elias-Smale SE, Proença RV, Koller MT, Kavousi M, van Rooij FJ, Hunink MG, Steyerberg EW, Hofman A, Oudkerk M, Witteman JC. Coronary calcium score improves classification of coronary heart disease risk in the elderly: the Rotterdam study. J Am Coll Cardiol. 2010;56:1407–14.
doi: 10.1016/j.jacc.2010.06.029
pubmed: 20946998
Zhu X, Yu J, Huang Z. Low-dose chest CT: optimizing radiation protection for patients. AJR Am J Roentgenol. 2004;183:809–16.
doi: 10.2214/ajr.183.3.1830809
pubmed: 15333374
Ludes C, Schaal M, Labani A, Jeung MY, Roy C, Ohana M. Scanner thoracique ultra-basse dose : la mort de la radiographie thoracique ? [Ultra-low dose chest CT: the end of chest radiograph?]. Presse Med. 2016;45:291–301.
doi: 10.1016/j.lpm.2015.12.003
pubmed: 26830922
Tækker M, Kristjánsdóttir B, Graumann O, Laursen CB, Pietersen PI. Diagnostic accuracy of low-dose and ultra-low-dose CT in detection of chest pathology: a systematic review. Clin Imaging. 2021;74:139–48.
doi: 10.1016/j.clinimag.2020.12.041
pubmed: 33517021
Shreya D, Zamora DI, Patel GS, Grossmann I, Rodriguez K, Soni M, Joshi PK, Patel SC, Sange I. Coronary artery calcium score - a reliable indicator of coronary artery disease? Cureus. 2021;13:e20149.
pubmed: 35003981
pmcid: 8723785
Ferencik M, Pencina KM, Liu T, Ghemigian K, Baltrusaitis K, Massaro JM, D’Agostino RB Sr, O’Donnell CJ, Hoffmann U. Coronary artery calcium distribution is an independent predictor of incident major coronary heart disease events: results from the framingham heart study. Circ Cardiovasc Imaging. 2017;10:e006592.
doi: 10.1161/CIRCIMAGING.117.006592
pubmed: 28956774
pmcid: 5659296
Greenland P, Blaha MJ, Budoff MJ, Erbel R, Watson KE. Coronary calcium score and cardiovascular risk. J Am Coll Cardiol. 2018;72:434–47.
doi: 10.1016/j.jacc.2018.05.027
pubmed: 30025580
pmcid: 6056023
McClelland RL, Chung H, Detrano R, Post W, Kronmal RA. Distribution of coronary artery calcium by race, gender, and age: results from the Multi-Ethnic Study of Atherosclerosis (MESA). Circulation. 2006;113:30–7.
doi: 10.1161/CIRCULATIONAHA.105.580696
pubmed: 16365194
Antman EM, Cohen M, Bernink PJ, McCabe CH, Horacek T, Papuchis G, Mautner B, Corbalan R, Radley D, Braunwald E. The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision making. JAMA. 2000;284:835–42.
doi: 10.1001/jama.284.7.835
pubmed: 10938172
Gottlieb I, Miller JM, Arbab-Zadeh A, Dewey M, Clouse ME, Sara L, Niinuma H, Bush DE, Paul N, Vavere AL, Texter J, Brinker J, Lima JA, Rochitte CE. The absence of coronary calcification does not exclude obstructive coronary artery disease or the need for revascularization in patients referred for conventional coronary angiography. J Am Coll Cardiol. 2010;55:627–34.
doi: 10.1016/j.jacc.2009.07.072
pubmed: 20170786
pmcid: 3294287
Sprivulis PC, Da Silva JA, Jacobs IG, Frazer AR, Jelinek GA. The association between hospital overcrowding and mortality among patients admitted via Western Australian emergency departments. Med J Aust. 2006;184:208–12.
doi: 10.5694/j.1326-5377.2006.tb00203.x
pubmed: 16515429
Singer AJ, Thode HC Jr, Viccellio P, Pines JM. The association between length of emergency department boarding and mortality. Acad Emerg Med. 2011;18:1324–9.
doi: 10.1111/j.1553-2712.2011.01236.x
pubmed: 22168198