title: hs-Troponin I Followed by CT Angiography Improves Acute Coronary Syndrome Risk Stratification Accuracy and Work-Up in Acute Chest Pain Patients: Results From ROMICAT II Trial.
abstract: OBJECTIVE
  This study compared diagnostic accuracy of conventional troponin/traditional coronary artery disease (CAD) assessment and highly sensitive troponin (hsTn) I/advanced CAD assessment for acute coronary syndrome (ACS) during the index hospitalization.
  
  
  BACKGROUND
  hsTnI and advanced assessment of CAD using coronary computed tomography angiography (CTA) are promising candidates to improve the accuracy of emergency department evaluation of patients with suspected ACS.
  
  
  METHODS
  We performed an observational cohort study in patients with suspected ACS enrolled in the ROMICAT II (Rule Out Myocardial Infarction/Ischemia using Computer Assisted Tomography) trial and randomized to coronary CTA who also had hsTnI measurement at the time of the emergency department presentation. We assessed coronary CTA for traditional (no CAD, nonobstructive CAD, ≥50% stenosis) and advanced features of CAD (≥50% stenosis, high-risk plaque features: positive remodeling, low <30-Hounsfield units plaque, napkin-ring sign, spotty calcium).
  
  
  RESULTS
  Of 160 patients (mean age: 53 ± 8 years, 40% women) 10.6% were diagnosed with ACS. The ACS rate in patients with hsTnI below the limit of detection (n = 9, 5.6%), intermediate (n = 139, 86.9%), and above the 99th percentile (n = 12, 7.5%) was 0%, 8.6%, and 58.3%, respectively. Absence of ≥50% stenosis and high-risk plaque ruled out ACS in patients with intermediate hsTnI (n = 87, 54.4%; ACS rate 0%), whereas patients with both ≥50% stenosis and high-risk plaque were at high risk (n = 13, 8.1%; ACS rate 69.2%) and patients with either ≥50% stenosis or high-risk plaque were at intermediate risk for ACS (n = 39, 24.4%; ACS rate 7.7%). hsTnI/advanced coronary CTA assessment significantly improved the diagnostic accuracy for ACS as compared to conventional troponin/traditional coronary CTA (area under the curve 0.84, 95% confidence interval [CI]: 0.80 to .88 vs. 0.74, 95% CI: 0.70 to 0.78; p < 0.001).
  
  
  CONCLUSIONS
  hsTnI at the time of presentation followed by early advanced coronary CTA assessment improves the risk stratification and diagnostic accuracy for ACS as compared to conventional troponin and traditional coronary CTA assessment. (Multicenter Study to Rule Out Myocardial Infarction/Ischemia by Cardiac Computed Tomography [ROMICAT-II]; NCT01084239).
authors.affiliation: Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR.|Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA.|Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA.
authors.forename: Maros
authors.initials: M
authors.lastname: Ferencik
authors.affiliation: Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA.|Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA.|Department of Radiology, First Affiliated Hospital of China Medical University, Shenyang, China.
authors.forename: Ting
authors.initials: T
authors.lastname: Liu
authors.affiliation: Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA.|Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA.
authors.forename: Thomas
authors.initials: T
authors.lastname: Mayrhofer
authors.affiliation: Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA.|Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA.|Department of Biomedical Imaging and Image-Guided Therapy, Medical University Vienna, Vienna, Austria.
authors.forename: Stefan B
authors.initials: SB
authors.lastname: Puchner
authors.affiliation: Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA.|Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA.
authors.forename: Michael T
authors.initials: MT
authors.lastname: Lu
authors.affiliation: TA-SE Lendület Cardiovascular Imaging Research Group, Heart and Vascular Centre, Semmelweis University, Budapest, Hungary.
authors.forename: Pal
authors.initials: P
authors.lastname: Maurovich-Horvat
authors.affiliation: Department of Emergency Medicine, Baystate Medical Center, Springfield, MA.
authors.forename: J Hector
authors.initials: JH
authors.lastname: Pope
authors.affiliation: Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA.|Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA.|Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital and Weill Cornell Medical College.
authors.forename: Quynh A
authors.initials: QA
authors.lastname: Truong
authors.affiliation: Division of Cardiology and the Cardio-Vascular Center, Tufts Medical Center, Boston, MA.
authors.forename: James E
authors.initials: JE
authors.lastname: Udelson
authors.affiliation: Department of Emergency Medicine, Baylor College of Medicine, Houston, TX.
authors.forename: W Frank
authors.initials: WF
authors.lastname: Peacock
authors.affiliation: University of Maryland School of Medicine, Baltimore, MD.
authors.forename: Charles S
authors.initials: CS
authors.lastname: White
authors.affiliation: Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO.
authors.forename: Pamela K
authors.initials: PK
authors.lastname: Woodard
authors.affiliation: Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD.
authors.forename: Jerome L
authors.initials: JL
authors.lastname: Fleg
authors.affiliation: Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA.
authors.forename: John T
authors.initials: JT
authors.lastname: Nagurney
authors.affiliation: Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA.
authors.forename: James L
authors.initials: JL
authors.lastname: Januzzi
authors.affiliation: Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA.|Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA.|Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA.
authors.forename: Udo
authors.initials: U
authors.lastname: Hoffmann
mesh_terms: D000328:Adult; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D054058:Acute Coronary Syndrome / Q000097:blood / Q000175:diagnosis / Q000000981:diagnostic imaging; D000787:Angina Pectoris / Q000097:blood / Q000175:diagnosis / Q000000981:diagnostic imaging; D015415:Biomarkers / Q000097:blood; D017023:Coronary Angiography / Q000379:methods; D003324:Coronary Artery Disease / Q000097:blood / Q000175:diagnosis / Q000000981:diagnostic imaging; D023921:Coronary Stenosis / Q000097:blood / Q000175:diagnosis / Q000000981:diagnostic imaging; D003331:Coronary Vessels / Q000000981:diagnostic imaging; D004636:Emergency Service, Hospital; D006760:Hospitalization; D058226:Plaque, Atherosclerotic; D011237:Predictive Value of Tests; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D014057:Tomography, X-Ray Computed; D019210:Troponin I / Q000097:blood; D014481:United States; D061205:Vascular Calcification / Q000097:blood / Q000175:diagnosis / Q000000981:diagnostic imaging
chemical_list: D015415:Biomarkers; D019210:Troponin I
keywords: acute coronary syndrome; coronary computed tomography angiography; coronary plaque; emergency department; highly sensitive troponin; risk stratification