Early resting myocardial computed tomography perfusion for the detection of acute coronary syndrome in patients with coronary artery disease.
BACKGROUND
Acute rest single-photon emission computed tomography-myocardial perfusion imaging (SPECT-MPI) has high predictive value for acute coronary syndrome (ACS) in emergency department patients. Prior studies have shown excellent agreement between rest/stress computed tomography perfusion (CTP) and SPECT-MPI, but the value of resting CTP (rCTP) in acute chest pain triage remains unclear. We sought to determine the diagnostic accuracy of early rCTP, incremental value beyond obstructive coronary artery disease (CAD; ≥50% stenosis), and compared early rCTP to late stress SPECT-MPI in patients with CAD presenting with suspicion of ACS to the emergency department.


RESULTS
In this prespecified subanalysis of 183 patients (58.1±10.2 years; 33% women), we included patients with any CAD by coronary computed tomography angiography (CCTA) from Rule Out Myocardial Infarction Using Computer-Assisted Tomography I. rCTP was assessed semiquantitatively, blinded to CAD interpretation. Overall, 31 had ACS and 48 had abnormal rCTP. Sensitivity and specificity of rCTP for ACS were 48% (95% confidence interval [CI], 30%-67%) and 78% (95% CI, 71%-85%), respectively. rCTP predicted ACS (adjusted odds ratio, 3.40 [95% CI, 1.37-8.42]; P=0.008) independently of obstructive CAD, and sensitivity for ACS increased from 77% (95% CI, 59%-90%) for obstructive CAD to 90% (95% CI, 74%-98%) with addition of rCTP (P=0.05). In a subgroup undergoing late rest/stress SPECT-MPI (n=81), CCTA/rCTP had noninferior discriminatory value to CCTA/SPECT-MPI (area under the curve, 0.88 versus 0.90; P=0.64) using a noninferiority margin of 10%.


CONCLUSIONS
Early rCTP provides incremental value beyond obstructive CAD to detect ACS. CCTA/rCTP is noninferior to CCTA/SPECT-MPI to discriminate ACS and presents an attractive alternative to triage patients presenting with acute chest pain.


BACKGROUND
http://www.clinicaltrials.gov. Unique identifier: NCT00990262.
From the Cardiovascular Division, NorthShore University HealthSystem, Evanston, IL (A.P.); Cardiac MR PET CT Program, Division of Cardiology, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston (A.P., A.M.L., T.M., W.A., S.U., M.F., S.B.P., U.H., B.B.G.); Department of Clinical Radiology, Ludwig-Maximilians University, Klinikum Grosshadern, Munich, Germany (F.B.); Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany (C.L.S.); and Division of Cardiology and Cardiovascular Center, Tufts Medical Center, Boston, MA (J.U.). apursnani@northshore.org.
Amit
A
Pursnani
From the Cardiovascular Division, NorthShore University HealthSystem, Evanston, IL (A.P.); Cardiac MR PET CT Program, Division of Cardiology, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston (A.P., A.M.L., T.M., W.A., S.U., M.F., S.B.P., U.H., B.B.G.); Department of Clinical Radiology, Ludwig-Maximilians University, Klinikum Grosshadern, Munich, Germany (F.B.); Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany (C.L.S.); and Division of Cardiology and Cardiovascular Center, Tufts Medical Center, Boston, MA (J.U.).
Ashley M
AM
Lee
From the Cardiovascular Division, NorthShore University HealthSystem, Evanston, IL (A.P.); Cardiac MR PET CT Program, Division of Cardiology, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston (A.P., A.M.L., T.M., W.A., S.U., M.F., S.B.P., U.H., B.B.G.); Department of Clinical Radiology, Ludwig-Maximilians University, Klinikum Grosshadern, Munich, Germany (F.B.); Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany (C.L.S.); and Division of Cardiology and Cardiovascular Center, Tufts Medical Center, Boston, MA (J.U.).
Thomas
T
Mayrhofer
From the Cardiovascular Division, NorthShore University HealthSystem, Evanston, IL (A.P.); Cardiac MR PET CT Program, Division of Cardiology, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston (A.P., A.M.L., T.M., W.A., S.U., M.F., S.B.P., U.H., B.B.G.); Department of Clinical Radiology, Ludwig-Maximilians University, Klinikum Grosshadern, Munich, Germany (F.B.); Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany (C.L.S.); and Division of Cardiology and Cardiovascular Center, Tufts Medical Center, Boston, MA (J.U.).
Waleed
W
Ahmed
From the Cardiovascular Division, NorthShore University HealthSystem, Evanston, IL (A.P.); Cardiac MR PET CT Program, Division of Cardiology, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston (A.P., A.M.L., T.M., W.A., S.U., M.F., S.B.P., U.H., B.B.G.); Department of Clinical Radiology, Ludwig-Maximilians University, Klinikum Grosshadern, Munich, Germany (F.B.); Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany (C.L.S.); and Division of Cardiology and Cardiovascular Center, Tufts Medical Center, Boston, MA (J.U.).
Shanmugam
S
Uthamalingam
From the Cardiovascular Division, NorthShore University HealthSystem, Evanston, IL (A.P.); Cardiac MR PET CT Program, Division of Cardiology, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston (A.P., A.M.L., T.M., W.A., S.U., M.F., S.B.P., U.H., B.B.G.); Department of Clinical Radiology, Ludwig-Maximilians University, Klinikum Grosshadern, Munich, Germany (F.B.); Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany (C.L.S.); and Division of Cardiology and Cardiovascular Center, Tufts Medical Center, Boston, MA (J.U.).
Maros
M
Ferencik
From the Cardiovascular Division, NorthShore University HealthSystem, Evanston, IL (A.P.); Cardiac MR PET CT Program, Division of Cardiology, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston (A.P., A.M.L., T.M., W.A., S.U., M.F., S.B.P., U.H., B.B.G.); Department of Clinical Radiology, Ludwig-Maximilians University, Klinikum Grosshadern, Munich, Germany (F.B.); Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany (C.L.S.); and Division of Cardiology and Cardiovascular Center, Tufts Medical Center, Boston, MA (J.U.).
Stefan B
SB
Puchner
From the Cardiovascular Division, NorthShore University HealthSystem, Evanston, IL (A.P.); Cardiac MR PET CT Program, Division of Cardiology, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston (A.P., A.M.L., T.M., W.A., S.U., M.F., S.B.P., U.H., B.B.G.); Department of Clinical Radiology, Ludwig-Maximilians University, Klinikum Grosshadern, Munich, Germany (F.B.); Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany (C.L.S.); and Division of Cardiology and Cardiovascular Center, Tufts Medical Center, Boston, MA (J.U.).
Fabian
F
Bamberg
From the Cardiovascular Division, NorthShore University HealthSystem, Evanston, IL (A.P.); Cardiac MR PET CT Program, Division of Cardiology, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston (A.P., A.M.L., T.M., W.A., S.U., M.F., S.B.P., U.H., B.B.G.); Department of Clinical Radiology, Ludwig-Maximilians University, Klinikum Grosshadern, Munich, Germany (F.B.); Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany (C.L.S.); and Division of Cardiology and Cardiovascular Center, Tufts Medical Center, Boston, MA (J.U.).
Christopher L
CL
Schlett
From the Cardiovascular Division, NorthShore University HealthSystem, Evanston, IL (A.P.); Cardiac MR PET CT Program, Division of Cardiology, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston (A.P., A.M.L., T.M., W.A., S.U., M.F., S.B.P., U.H., B.B.G.); Department of Clinical Radiology, Ludwig-Maximilians University, Klinikum Grosshadern, Munich, Germany (F.B.); Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany (C.L.S.); and Division of Cardiology and Cardiovascular Center, Tufts Medical Center, Boston, MA (J.U.).
James
J
Udelson
From the Cardiovascular Division, NorthShore University HealthSystem, Evanston, IL (A.P.); Cardiac MR PET CT Program, Division of Cardiology, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston (A.P., A.M.L., T.M., W.A., S.U., M.F., S.B.P., U.H., B.B.G.); Department of Clinical Radiology, Ludwig-Maximilians University, Klinikum Grosshadern, Munich, Germany (F.B.); Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany (C.L.S.); and Division of Cardiology and Cardiovascular Center, Tufts Medical Center, Boston, MA (J.U.).
Udo
U
Hoffmann
From the Cardiovascular Division, NorthShore University HealthSystem, Evanston, IL (A.P.); Cardiac MR PET CT Program, Division of Cardiology, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston (A.P., A.M.L., T.M., W.A., S.U., M.F., S.B.P., U.H., B.B.G.); Department of Clinical Radiology, Ludwig-Maximilians University, Klinikum Grosshadern, Munich, Germany (F.B.); Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Heidelberg, Germany (C.L.S.); and Division of Cardiology and Cardiovascular Center, Tufts Medical Center, Boston, MA (J.U.).
Brian B
BB
Ghoshhajra
D054058:Acute Coronary Syndrome / Q000000981:diagnostic imaging* / Q000503:physiopathology; D000368:Aged; D019540:Area Under Curve; D017023:Coronary Angiography / Q000379:methods*; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging* / Q000503:physiopathology; D003326:Coronary Circulation; D023921:Coronary Stenosis / Q000000981:diagnostic imaging* / Q000503:physiopathology; D003331:Coronary Vessels / Q000000981:diagnostic imaging* / Q000503:physiopathology; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D061330:Multidetector Computed Tomography; D015999:Multivariate Analysis; D055414:Myocardial Perfusion Imaging / Q000379:methods*; D016017:Odds Ratio; D011237:Predictive Value of Tests; D012372:ROC Curve; D015899:Tomography, Emission-Computed, Single-Photon
emergency service, hospital; perfusion; scanners; tomography, computed