title: Incremental value of cardiac imaging in patients presenting to the emergency department with chest pain and without ST-segment elevation: a multicenter study.
abstract: BACKGROUND
  We hypothesized that imaging of regional myocardial function (RF) and perfusion (PER) will add incremental value for both diagnosis and short-term prognosis to routine demographic, clinical, and electrocardiographic findings in patients presenting to the emergency department (ED) with chest pain and without ST-segment elevation on the electrocardiogram.
  
  
  METHODS
  We compared contrast echocardiography (CE) with gated single-photon emission computed tomography (SPECT) for this purpose. Both CE and SPECT readings included separate and composite assessments of both RF and PER. Adverse events in the first 48 hours after ED presentation included acute myocardial infarction, emergent revascularization, and cardiac-related death.
  
  
  RESULTS
  Concordance between CE and SPECT was 77% (73% to 82%) for all territories, with a higher concordance for the anterior wall of 84% (78% to 89%). Of the 203 patients recruited for the study, 38 (19%) had a cardiac event within 48 hours of ED presentation: 21 had acute myocardial infarction, 16 underwent an urgent revascularization procedure, and 1 died. In multivariate logistic regression models, the number of abnormal segments on CE and SPECT were significant predictors (P <.05) of cardiac events. The composite scores on CE provided 17% incremental information (P =.009, n = 203) and gated SPECT provided 23.5% additional information (P =.020, n = 163) for predicting cardiac events compared with routine demographic, clinical, and electrocardiographic variables. RF and composite evaluation was superior on SPECT compared with CE, whereas PER alone was not.
  
  
  CONCLUSIONS
  Cardiac imaging of RF and PER at the time of ED presentation offers substantially greater diagnostic and prognostic information for early cardiac events in patients presenting to the ED with chest pain and no ST elevation than does the routine demographic, clinical, and electrocardiographic assessment.
authors.affiliation: Cardiovascular Imaging Center, Cardiovascular Division, University of Virginia, Charlottesville, Va 22908-0158, USA. sk@virginia.edu
authors.forename: Sanjiv
authors.initials: S
authors.lastname: Kaul
authors.forename: Roxy
authors.initials: R
authors.lastname: Senior
authors.forename: Christian
authors.initials: C
authors.lastname: Firschke
authors.forename: Xin-Qun
authors.initials: XQ
authors.lastname: Wang
authors.forename: Jonathan
authors.initials: J
authors.lastname: Lindner
authors.forename: Flordeliza S
authors.initials: FS
authors.lastname: Villanueva
authors.forename: Soroosh
authors.initials: S
authors.lastname: Firozan
authors.forename: Michael C
authors.initials: MC
authors.lastname: Kontos
authors.forename: Allen
authors.initials: A
authors.lastname: Taylor
authors.forename: Ian J
authors.initials: IJ
authors.lastname: Nixon
authors.forename: Denny D
authors.initials: DD
authors.lastname: Watson
authors.forename: Frank E
authors.initials: FE
authors.lastname: Harrell
mesh_terms: D002637:Chest Pain / Q000209:etiology*; D003327:Coronary Disease / Q000175:diagnosis* / Q000000981:diagnostic imaging; D004452:Echocardiography; D004562:Electrocardiography; D004636:Emergency Service, Hospital; D005260:Female; D006321:Heart / Q000000981:diagnostic imaging; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D011446:Prospective Studies; D019275:Radiopharmaceuticals; D012680:Sensitivity and Specificity; D016037:Single-Blind Method; D017256:Technetium Tc 99m Sestamibi; D015899:Tomography, Emission-Computed, Single-Photon
chemical_list: D019275:Radiopharmaceuticals; D017256:Technetium Tc 99m Sestamibi