Coronary computed tomography angiography improves assessment of patients with acute chest pain and inconclusively elevated high-sensitivity troponins.
Acute coronary syndrome
Computed tomography angiography
Non-ST elevated myocardial infarction
Troponin
Journal
European radiology
ISSN: 1432-1084
Titre abrégé: Eur Radiol
Pays: Germany
ID NLM: 9114774
Informations de publication
Date de publication:
16 Aug 2024
16 Aug 2024
Historique:
received:
06
11
2023
accepted:
03
06
2024
revised:
14
05
2024
medline:
16
8
2024
pubmed:
16
8
2024
entrez:
16
8
2024
Statut:
aheadofprint
Résumé
To determine whether coronary computed tomography angiography (CCTA) can improve the diagnostic work-up of patients with acute chest pain and inconclusively high-sensitivity troponins (hs-troponin). We conducted a prospective, blinded, observational, multicentre study. Patients aged 30-80 years presenting to the emergency department with acute chest pain and inconclusively elevated hs-troponins were included and underwent CCTA. The primary outcome was the diagnostic accuracy of ≥ 50% stenosis on CCTA to identify patients with type-1 non-ST-segment elevation acute coronary syndrome (NSTE-ACS). A total of 106 patients (mean age 65 ± 10, 29% women) were enrolled of whom 20 patients (19%) had an adjudicated diagnosis of type-1 NSTE-ACS. In 45 patients, CCTA revealed non-obstructive coronary artery disease (CAD) or no CAD. Sensitivity, specificity, negative predictive value (NPV), positive predictive value and area-under-the-curve (AUC) of ≥ 50% stenosis on CCTA to identify patients with type 1 NSTE-ACS, was 95% (95% confidence interval: 74-100), 56% (45-68), 98% (87-100), 35% (29-41) and 0.83 (0.73-0.94), respectively. When only coronary segments with a diameter ≥ 2 mm were considered for the adjudication of type 1 NSTE-ACS, the sensitivity and NPV increased to 100%. In 8 patients, CCTA enabled the detection of clinically relevant non-coronary findings. The absence of ≥ 50% coronary artery stenosis on CCTA can be used to rule out type 1 NSTE-ACS in acute chest pain patients with inconclusively elevated hs-troponins. Additionally, CCTA can help improve the diagnostic work-up by detecting other relevant conditions that cause acute chest pain and inconclusively elevated hs-troponins. Coronary CTA (CCTA) can safely rule out type 1 non-ST-segment elevation acute coronary syndrome (NSTE-ACS) in patients presenting to the ED with acute chest pain and inconclusively elevated hs-troponins, while also detecting other relevant non-coronary conditions. Clinicaltrials.gov (NCT03129659). Registered on 26 April 2017 KEY POINTS: Acute chest discomfort is a common presenting complaint in the emergency department. CCTA achieved very high negative predictive values for type 1 NSTE-ACS in this population. CCTA can serve as an adjunct for evaluating equivocal ACS and evaluates for other pathology.
Identifiants
pubmed: 39150488
doi: 10.1007/s00330-024-10930-1
pii: 10.1007/s00330-024-10930-1
doi:
Banques de données
ClinicalTrials.gov
['NCT03129659']
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Informations de copyright
© 2024. The Author(s).
Références
Goodacre S, Cross E, Arnold J, Angelini K, Capewell S, Nicholl J (2005) The health care burden of acute chest pain. Heart 91:229–230
doi: 10.1136/hrt.2003.027599
pubmed: 15657244
pmcid: 1768669
Collet JP, Thiele H, Barbato E et al (2020) 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 42:1289–1367
Reichlin T, Twerenbold R, Wildi K et al (2015) Prospective validation of a 1-hour algorithm to rule-out and rule-in acute myocardial infarction using a high-sensitivity cardiac troponin T assay. Can Med Assoc J 187:E243
doi: 10.1503/cmaj.141349
Mueller C, Giannitsis E, Christ M et al (2016) Multicenter evaluation of a 0-hour/1-hour algorithm in the diagnosis of myocardial infarction with high-sensitivity cardiac troponin T. Ann Emerg Med 68:76–87.e74
doi: 10.1016/j.annemergmed.2015.11.013
pubmed: 26794254
Nestelberger T, Wildi K, Boeddinghaus J et al (2016) Characterization of the observe zone of the ESC 2015 high-sensitivity cardiac troponin 0h/1h-algorithm for the early diagnosis of acute myocardial infarction. Int J Cardiol 207:238–245
doi: 10.1016/j.ijcard.2016.01.112
pubmed: 26808985
Hoffmann U, Truong QA, Schoenfeld DA et al (2012) Coronary CT angiography versus standard evaluation in acute chest pain. N Engl J Med 367:299–308
doi: 10.1056/NEJMoa1201161
pubmed: 22830462
pmcid: 3662217
Arslan M, Schaap J, Van Gorsel B et al (2021) Coronary CT angiography for improved assessment of patients with acute chest pain and low-range positive high-sensitivity troponins: study protocol for a prospective, observational, multicentre study (COURSE trial). BMJ Open 11:e049349
doi: 10.1136/bmjopen-2021-049349
pubmed: 34663657
pmcid: 8524275
Cury RC, Abbara S, Achenbach S et al (2016) CAD-RADS™: Coronary Artery Disease—Reporting and Data System: An Expert Consensus Document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Radiology (ACR) and the North American Society for Cardiovascular Imaging (NASCI). Endorsed by the American College of Cardiology. J Am Coll Radiol 13:1458–1466.e1459
doi: 10.1016/j.jacr.2016.04.024
pubmed: 27318576
Thygesen K, Alpert JS, Jaffe AS et al (2018) Fourth universal definition of myocardial infarction. Eur Heart J 40:237–269
Goldstein JA, Chinnaiyan KM, Abidov A et al (2011) The CT-STAT (Coronary Computed Tomographic Angiography for Systematic Triage of Acute Chest Pain Patients to Treatment) trial. J Am Coll Cardiol 58:1414–1422
doi: 10.1016/j.jacc.2011.03.068
pubmed: 21939822
Litt HI, Gatsonis C, Snyder B et al (2012) CT angiography for safe discharge of patients with possible acute coronary syndromes. N Engl J Med 366:1393–1403
doi: 10.1056/NEJMoa1201163
pubmed: 22449295
Hoffmann U, Bamberg F, Chae CU et al (2009) Coronary computed tomography angiography for early triage of patients with acute chest pain: the ROMICAT (Rule Out Myocardial Infarction using Computer Assisted Tomography) Trial. J Am Coll Cardiol 53:1642–1650
doi: 10.1016/j.jacc.2009.01.052
pubmed: 19406338
pmcid: 2747766
Dedic A, Lubbers MM, Schaap J et al (2016) Coronary CT angiography for suspected ACS in the era of high-sensitivity troponins: randomized multicenter study. J Am Coll Cardiol 67:16–26
doi: 10.1016/j.jacc.2015.10.045
pubmed: 26764061
Gulati M, Levy PD, Mukherjee D et al (2021) 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 144:e368–e454
pubmed: 34709928
Kofoed KF, Engstrøm T, Sigvardsen PE et al (2021) Prognostic value of coronary CT angiography in patients with non-ST-segment elevation acute coronary syndromes. J Am Coll Cardiol 77:1044–1052
doi: 10.1016/j.jacc.2020.12.037
pubmed: 33632478
Linde JJ, Kelbæk H, Hansen TF et al (2020) Coronary CT Angiography in Patients With Non-ST-Segment Elevation Acute Coronary Syndrome. J Am Coll Cardiol 75:453–463
doi: 10.1016/j.jacc.2019.12.012
pubmed: 32029126
Smulders MW, Kietselaer B, Wildberger JE et al (2019) Initial imaging-guided strategy versus routine care in patients with non-ST-segment elevation myocardial infarction. J Am Coll Cardiol 74:2466–2477
doi: 10.1016/j.jacc.2019.09.027
pubmed: 31727284
Arnett DK, Blumenthal RS, Albert MA et al (2019) 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 140:e596–e646
pubmed: 30879355
pmcid: 7734661
Mach F, Baigent C, Catapano AL et al (2020) 2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk. Eur Heart J 41:111–188
doi: 10.1093/eurheartj/ehz455
pubmed: 31504418