title: Incremental value of myocardial perfusion over regional left ventricular function and coronary stenosis by cardiac CT for the detection of acute coronary syndromes in high-risk patients: a subgroup analysis of the ROMICAT trial.
abstract: OBJECTIVE
  To determine the incremental benefit of assessing myocardial perfusion defects (MPD) for acute coronary syndromes (ACS) over coronary and functional assessment by rest cardiac computed tomography (CT) in patients with acute chest pain.
  
  
  BACKGROUND
  Assessment of myocardial perfusion is feasible with cardiac CT; however, the diagnostic value of this assessment in patients at risk for ACS has not been demonstrated.
  
  
  METHODS
  The study included patients who presented to the emergency department with acute chest pain, nonischemic initial electrocardiogram (ECG), and negative cardiac biomarkers but had clinical suspicion for ACS and underwent invasive coronary angiography (ICA). Results were blinded to caregivers and patients. CT data sets were independently assessed for the presence of coronary plaque and stenosis, regional left ventricular function, and myocardial perfusion deficits by 2 blinded observers. Coronary angiography was assessed for the presence of stenosis, TIMI myocardial perfusion grade, and corrected TIMI frame count. The endpoint was ACS during index hospitalization.
  
  
  RESULTS
  We analyzed data from 35 subjects (69% male, mean age 58 ± 9 years) of whom 22 (63%) had ACS. The sensitivity and specificity of MPD for ACS were 86% (95% CI: 64%-96%) and 62% (95% CI: 32%-85%), respectively. Combined, MPD and RWMA assessment resulted in specificity and sensitivity of 86% (95% CI: 64%-96%) and 85% (95% CI: 54%-97%), respectively. Adding MPD and RWMA to the assessment for significant stenosis (>50%) resulted in a higher sensitivity of 91% (69-98%) and specificity of 85% (54-97%) and a significantly increased overall diagnostic accuracy when compared with assessment for stenosis (AUC: 0.88 vs 0.79; respectively, P = 0.02). Diagnostic accuracy of CT was not associated with impaired CTFC >40 or myocardial TIMI perfusion grade < 3.
  
  
  CONCLUSIONS
  Assessment of myocardial perfusion and regional wall motion abnormalities may enhance the ability of CT to detect ACS in patients with acute chest pain.
authors.affiliation: Cardiac MR PET CT Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
authors.forename: Hiram G
authors.initials: HG
authors.lastname: Bezerra
authors.forename: Ricardo
authors.initials: R
authors.lastname: Loureiro
authors.forename: Thomas
authors.initials: T
authors.lastname: Irlbeck
authors.forename: Fabian
authors.initials: F
authors.lastname: Bamberg
authors.forename: Christopher L
authors.initials: CL
authors.lastname: Schlett
authors.forename: Ian
authors.initials: I
authors.lastname: Rogers
authors.forename: Ron
authors.initials: R
authors.lastname: Blankstein
authors.forename: Quynh A
authors.initials: QA
authors.lastname: Truong
authors.forename: Thomas J
authors.initials: TJ
authors.lastname: Brady
authors.forename: Ricardo C
authors.initials: RC
authors.lastname: Cury
authors.forename: Udo
authors.initials: U
authors.lastname: Hoffmann
mesh_terms: D054058:Acute Coronary Syndrome / Q000000981:diagnostic imaging* / Q000503:physiopathology; D000368:Aged; D000787:Angina Pectoris / Q000000981:diagnostic imaging / Q000503:physiopathology; D016009:Chi-Square Distribution; D017023:Coronary Angiography; D003326:Coronary Circulation; D023921:Coronary Stenosis / Q000000981:diagnostic imaging* / Q000503:physiopathology; D004311:Double-Blind Method; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D055414:Myocardial Perfusion Imaging / Q000379:methods*; D015588:Observer Variation; D011237:Predictive Value of Tests; D011379:Prognosis; D011446:Prospective Studies; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D014057:Tomography, X-Ray Computed; D018487:Ventricular Dysfunction, Left / Q000000981:diagnostic imaging* / Q000503:physiopathology; D016277:Ventricular Function, Left