Incremental value of cardiac imaging in patients presenting to the emergency department with chest pain and without ST-segment elevation: a multicenter study.
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.
Kaul
Sanjiv
S
Cardiovascular Imaging Center, Cardiovascular Division, University of Virginia, Charlottesville, Va 22908-0158, USA. sk@virginia.edu
Senior
Roxy
R
Firschke
Christian
C
Wang
Xin-Qun
XQ
Lindner
Jonathan
J
Villanueva
Flordeliza S
FS
Firozan
Soroosh
S
Kontos
Michael C
MC
Taylor
Allen
A
Nixon
Ian J
IJ
Watson
Denny D
DD
Harrell
Frank E
FE
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
D019275:Radiopharmaceuticals; D017256:Technetium Tc 99m Sestamibi