title: Coronary computed tomography angiography for early triage of patients with acute chest pain: the ROMICAT (Rule Out Myocardial Infarction using Computer Assisted Tomography) trial.
abstract: OBJECTIVE
  This study was designed to determine the usefulness of coronary computed tomography angiography (CTA) in patients with acute chest pain.
  
  
  BACKGROUND
  Triage of chest pain patients in the emergency department remains challenging.
  
  
  METHODS
  We used an observational cohort study in chest pain patients with normal initial troponin and nonischemic electrocardiogram. A 64-slice coronary CTA was performed before admission to detect coronary plaque and stenosis (>50% luminal narrowing). Results were not disclosed. End points were acute coronary syndrome (ACS) during index hospitalization and major adverse cardiac events during 6-month follow-up.
  
  
  RESULTS
  Among 368 patients (mean age 53 +/- 12 years, 61% men), 31 had ACS (8%). By coronary CTA, 50% of these patients were free of coronary artery disease (CAD), 31% had nonobstructive disease, and 19% had inconclusive or positive computed tomography for significant stenosis. Sensitivity and negative predictive value for ACS were 100% (n = 183 of 368; 95% confidence interval [CI]: 98% to 100%) and 100% (95% CI: 89% to 100%), respectively, with the absence of CAD and 77% (95% CI: 59% to 90%) and 98% (n = 300 of 368, 95% CI: 95% to 99%), respectively, with significant stenosis by coronary CTA. Specificity of presence of plaque and stenosis for ACS were 54% (95% CI: 49% to 60%) and 87% (95% CI: 83% to 90%), respectively. Only 1 ACS occurred in the absence of calcified plaque. Both the extent of coronary plaque and presence of stenosis predicted ACS independently and incrementally to Thrombolysis In Myocardial Infarction risk score (area under curve: 0.88, 0.82, vs. 0.63, respectively; all p < 0.0001).
  
  
  CONCLUSIONS
  Fifty percent of patients with acute chest pain and low to intermediate likelihood of ACS were free of CAD by computed tomography and had no ACS. Given the large number of such patients, early coronary CTA may significantly improve patient management in the emergency department.
authors.affiliation: Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114, USA. uhoffmann@partners.org
authors.forename: Udo
authors.initials: U
authors.lastname: Hoffmann
authors.forename: Fabian
authors.initials: F
authors.lastname: Bamberg
authors.forename: Claudia U
authors.initials: CU
authors.lastname: Chae
authors.forename: John H
authors.initials: JH
authors.lastname: Nichols
authors.forename: Ian S
authors.initials: IS
authors.lastname: Rogers
authors.forename: Sujith K
authors.initials: SK
authors.lastname: Seneviratne
authors.forename: Quynh A
authors.initials: QA
authors.lastname: Truong
authors.forename: Ricardo C
authors.initials: RC
authors.lastname: Cury
authors.forename: Suhny
authors.initials: S
authors.lastname: Abbara
authors.forename: Michael D
authors.initials: MD
authors.lastname: Shapiro
authors.forename: Jamaluddin
authors.initials: J
authors.lastname: Moloo
authors.forename: Javed
authors.initials: J
authors.lastname: Butler
authors.forename: Maros
authors.initials: M
authors.lastname: Ferencik
authors.forename: Hang
authors.initials: H
authors.lastname: Lee
authors.forename: Ik-Kyung
authors.initials: IK
authors.lastname: Jang
authors.forename: Blair A
authors.initials: BA
authors.lastname: Parry
authors.forename: David F
authors.initials: DF
authors.lastname: Brown
authors.forename: James E
authors.initials: JE
authors.lastname: Udelson
authors.forename: Stephan
authors.initials: S
authors.lastname: Achenbach
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Brady
authors.forename: John T
authors.initials: JT
authors.lastname: Nagurney
mesh_terms: D054058:Acute Coronary Syndrome / Q000175:diagnosis* / Q000503:physiopathology; D000208:Acute Disease; D002140:California; D002637:Chest Pain / Q000175:diagnosis* / Q000503:physiopathology; D016001:Confidence Intervals; D017023:Coronary Angiography / Q000379:methods; D003937:Diagnosis, Differential; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D011446:Prospective Studies; D012372:ROC Curve; D012307:Risk Factors; D012680:Sensitivity and Specificity; D016037:Single-Blind Method; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D014218:Triage / Q000706:statistics & numerical data*