title: Prognostic value of CT angiography for major adverse cardiac events in patients with acute chest pain from the emergency department: 2-year outcomes of the ROMICAT trial.
abstract: OBJECTIVE
  The aim of this study was to determine the 2-year prognostic value of cardiac computed tomography (CT) for predicting major adverse cardiac events (MACE) in patients presenting to the emergency department (ED) with acute chest pain.
  
  
  BACKGROUND
  CT has high potential for early triage of acute chest pain patients. However, there is a paucity of data regarding the prognostic value of CT in this ED cohort.
  
  
  METHODS
  We followed 368 patients from the ROMICAT (Rule Out Myocardial Infarction Using Computer Assisted Tomography) trial (age 53 ± 12 years; 61% male) who presented to the ED with acute chest pain, negative initial troponin, and a nonischemic electrocardiogram for 2 years. Contrast-enhanced 64-slice CT was obtained during index hospitalization, and caregivers and patients remained blinded to the results. CT was assessed for the presence of plaque, stenosis (>50% luminal narrowing), and left ventricular regional wall motion abnormalities (RWMA). The primary endpoint was MACE, defined as composite cardiac death, nonfatal myocardial infarction, or coronary revascularization.
  
  
  RESULTS
  Follow-up was completed in 333 patients (90.5%) with a median follow-up period of 23 months. At the end of the follow-up period, 25 patients (6.8%) experienced 35 MACE (no cardiac deaths, 12 myocardial infarctions, and 23 revascularizations). Cumulative probability of 2-year MACE increased across CT strata for coronary artery disease (CAD) (no CAD 0%; nonobstructive CAD 4.6%; obstructive CAD 30.3%; log-rank p < 0.0001) and across combined CT strata for CAD and RWMA (no stenosis or RWMA 0.9%; 1 feature-either RWMA [15.0%] or stenosis [10.1%], both stenosis and RWMA 62.4%; log-rank p < 0.0001). The c statistic for predicting MACE was 0.61 for clinical Thrombolysis In Myocardial Infarction risk score and improved to 0.84 by adding CT CAD data and improved further to 0.91 by adding RWMA (both p < 0.0001).
  
  
  CONCLUSIONS
  CT coronary and functional features predict MACE and have incremental prognostic value beyond clinical risk score in ED patients with acute chest pain. The absence of CAD on CT provides a 2-year MACE-free warranty period, whereas coronary stenosis with RWMA is associated with the highest risk of MACE.
authors.affiliation: Cardiac MR PET CT Program, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.
authors.forename: Christopher L
authors.initials: CL
authors.lastname: Schlett
authors.forename: Dahlia
authors.initials: D
authors.lastname: Banerji
authors.forename: Emily
authors.initials: E
authors.lastname: Siegel
authors.forename: Fabian
authors.initials: F
authors.lastname: Bamberg
authors.forename: Sam J
authors.initials: SJ
authors.lastname: Lehman
authors.forename: Maros
authors.initials: M
authors.lastname: Ferencik
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Brady
authors.forename: John T
authors.initials: JT
authors.lastname: Nagurney
authors.forename: Udo
authors.initials: U
authors.lastname: Hoffmann
authors.forename: Quynh A
authors.initials: QA
authors.lastname: Truong
mesh_terms: D000328:Adult; D000368:Aged; D000787:Angina Pectoris / Q000000981:diagnostic imaging* / Q000209:etiology / Q000401:mortality / Q000628:therapy; D001900:Boston; D002637:Chest Pain / Q000000981:diagnostic imaging* / Q000209:etiology / Q000401:mortality; D016009:Chi-Square Distribution; D003287:Contrast Media; D017023:Coronary Angiography / Q000379:methods*; D023921:Coronary Stenosis / Q000150:complications / Q000000981:diagnostic imaging* / Q000401:mortality / Q000628:therapy; D004311:Double-Blind Method; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000209:etiology / Q000401:mortality / Q000628:therapy; D009204:Myocardial Revascularization; D011237:Predictive Value of Tests; D011379:Prognosis; D016016:Proportional Hazards Models; D011446:Prospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D013997:Time Factors; D014057:Tomography, X-Ray Computed; D014218:Triage
chemical_list: D003287:Contrast Media