Usefulness of 64-slice cardiac computed tomographic angiography for diagnosing acute coronary syndromes and predicting clinical outcome in emergency department patients with chest pain of uncertain origin.
BACKGROUND
Multidetector computed tomography (MDCT) has high diagnostic value for detecting or excluding coronary artery stenosis. We examined performance characteristics of MDCT for diagnosing or excluding an acute coronary syndrome in patients presenting to the emergency department (ED) with possible ischemic chest pain and examined relation to clinical outcome during a 15-month follow-up period.


RESULTS
We prospectively studied 58 patients (56+/-10 years of age, 36% female) with chest pain possibly ischemic in origin and no new ECG changes or elevated biomarkers. The patients underwent 64-slice contrast-enhanced MDCT, which showed normal coronary vessels (no or trivial atheroma) in 15 patients, nonobstructive plaque in 20 (MDCT-negative patients), and obstructive coronary disease (> or = 50% luminal narrowing) in 23 (MDCT-positive group). By further investigation (new elevation of cardiac biomarkers, abnormal myocardial perfusion scintigraphy and/or invasive angiography), acute coronary syndrome was diagnosed in 20 of the 23 MDCT-positive patients (ED MDCT sensitivity 100% [20/20], specificity 92% [35/38], positive predictive value 87% [20/23], negative predictive value 100% [35/35]). During a 15-month follow-up period, no deaths or myocardial infarctions occurred in the 35 patients discharged from the ED after initial triage and MDCT findings. One patient underwent late percutaneous coronary intervention (late major adverse cardiovascular events rate, 2.8%). Overall, ED MDCT sensitivity for predicting major adverse cardiovascular events (death, myocardial infarction, or revascularization) during hospitalization and follow-up was 92% (12/13), specificity was 76% (34/45), positive predictive value was 52% (12/23), and negative predictive value was 97% (34/35).


CONCLUSIONS
We found that 64-slice cardiac MDCT is a potentially valuable diagnostic tool in ED patients with chest pain of uncertain origin, providing early direct noninvasive visualization of coronary anatomy. ED MDCT had high positive predictive value for diagnosing acute coronary syndrome, whereas a negative MDCT study predicted a low rate of major adverse cardiovascular events and favorable outcome during follow-up.
Rubinshtein
Ronen
R
Department of Cardiovascular Medicine, Lady Davis Carmel Medical Center and the Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.
Halon
David A
DA
Gaspar
Tamar
T
Jaffe
Ronen
R
Karkabi
Basheer
B
Flugelman
Moshe Y
MY
Kogan
Asia
A
Shapira
Reuma
R
Peled
Nathan
N
Lewis
Basil S
BS
D000208:Acute Disease; D000368:Aged; D000789:Angina, Unstable / Q000097:blood / Q000000981:diagnostic imaging* / Q000628:therapy; D015415:Biomarkers / Q000097:blood; D002114:Calcinosis / Q000000981:diagnostic imaging; D002118:Calcium / Q000032:analysis; D002318:Cardiovascular Diseases / Q000401:mortality; D002637:Chest Pain / Q000175:diagnosis* / Q000209:etiology; D017023:Coronary Angiography / Q000379:methods* / Q000706:statistics & numerical data; D003937:Diagnosis, Differential; D004562:Electrocardiography; D004630:Emergencies; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D005080:Exercise Test; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000097:blood / Q000000981:diagnostic imaging* / Q000628:therapy; D009204:Myocardial Revascularization / Q000706:statistics & numerical data; D010351:Patient Discharge; D011237:Predictive Value of Tests; D011446:Prospective Studies; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D036542:Tomography, Spiral Computed / Q000706:statistics & numerical data; D014218:Triage / Q000379:methods; D020107:Troponin T / Q000097:blood
D015415:Biomarkers; D020107:Troponin T; D002118:Calcium