Coronary computed tomography angiography for early triage of patients with acute chest pain: the ROMICAT (Rule Out Myocardial Infarction using Computer Assisted Tomography) trial.
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.
Hoffmann
Udo
U
Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 02114, USA. uhoffmann@partners.org
Bamberg
Fabian
F
Chae
Claudia U
CU
Nichols
John H
JH
Rogers
Ian S
IS
Seneviratne
Sujith K
SK
Truong
Quynh A
QA
Cury
Ricardo C
RC
Abbara
Suhny
S
Shapiro
Michael D
MD
Moloo
Jamaluddin
J
Butler
Javed
J
Ferencik
Maros
M
Lee
Hang
H
Jang
Ik-Kyung
IK
Parry
Blair A
BA
Brown
David F
DF
Udelson
James E
JE
Achenbach
Stephan
S
Brady
Thomas J
TJ
Nagurney
John T
JT
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*