51
|
Beache GM, Mohammed TLH, Hurwitz Koweek LM, Ghoshhajra BB, Brown RKJ, Davis AM, Heitner J, Hsu JY, Johri AM, Khosa F, Kligerman SJ, Litmanovich D, Maroules CD, Meyersohn N, Tomaszewski CA, Villines TC, Wann S, Abbara S. ACR Appropriateness Criteria® Acute Nonspecific Chest Pain-Low Probability of Coronary Artery Disease. J Am Coll Radiol 2020; 17:S346-S354. [PMID: 33153548 DOI: 10.1016/j.jacr.2020.09.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 09/01/2020] [Indexed: 12/19/2022]
Abstract
Patients with acute nonspecific chest pain and low probability for coronary disease remain an important clinical management dilemma. We focus on evidence for imaging, in an integrated decision-making setting. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
Collapse
Affiliation(s)
- Garth M Beache
- University of Louisville School of Medicine, Louisville, Kentucky.
| | | | | | | | | | - Andrew M Davis
- The University of Chicago Medical Center, Chicago, Illinois; American College of Physicians
| | - John Heitner
- New York Presbyterian Methodist Hospital, Brooklyn, New York; Society for Cardiovascular Magnetic Resonance
| | - Joe Y Hsu
- Kaiser Permanente, Los Angeles, California
| | - Amer M Johri
- Queen's University, Kingston, Ontario; Canada, Cardiology expert
| | - Faisal Khosa
- Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | | | | | | | | | - Todd C Villines
- University of Virginia Health Center, Charlottesville, Virginia; Society of Cardiovascular Computed Tomography
| | - Samuel Wann
- Ascension Healthcare Wisconsin, Milwaukee, Wisconsin; Nuclear cardiology expert
| | - Suhny Abbara
- Specialty Chair, UT Southwestern Medical Center, Dallas, Texas
| |
Collapse
|
52
|
Shah NR, Bittencourt MS, Winchester DE. All Together Now: Synthesizing Evidence-Based Protocols to Simplify and Expedite Emergency Department Evaluation of Low-Risk Patients. J Nucl Cardiol 2020; 27:1349-1351. [PMID: 31452086 DOI: 10.1007/s12350-019-01858-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 08/06/2019] [Indexed: 11/24/2022]
Affiliation(s)
- Nishant R Shah
- Division of Cardiology, Department of Medicine, Brown University Alpert Medical School, 830 Chalkstone Ave, Providence, RI, 02908, USA.
| | - Marcio S Bittencourt
- Division of Internal Medicine, University Hospital, University of Sao Paulo, Sao Paulo, Brazil
| | - David E Winchester
- Malcolm Randall VA Medical Center, Department of Medicine, University of Florida College of Medicine, Gainesville, FL, USA
| |
Collapse
|
53
|
Impact of Education-based HEART Score Pathway on Coronary Computed Tomography Angiography Utilization and Yield in the Emergency Department. Crit Pathw Cardiol 2020; 19:200-205. [PMID: 32701592 DOI: 10.1097/hpc.0000000000000234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE There is a growing consensus to reduce unnecessary testing among low-risk chest pain patients. The objective of this study was to evaluate the impact of implementing an education-based HEART score pathway in the emergency department on coronary computed tomography angiography (CCTA) utilization and yield. METHODS A retrospective before and after intervention study was conducted at a single site. Adult emergency department patients undergoing CCTA for suspected acute coronary syndrome were included. Primary outcomes were CCTA utilization and yield. Utilization was defined as the percentage of patients evaluated with CCTA and yield was calculated as the percentage of patients with a diagnosis of obstructive coronary artery disease, defined as ≥50% stenosis in any one coronary artery due to atherosclerosis. RESULTS 1540 patients undergoing CCTAs were included. CCTA utilization before and after were 2.2% [95% confidence interval (CI) 2.0-2.3] and 2.0% (95% CI 1.9-2.2), respectively; mean difference 0.1% (95% CI -0.1 to 0.3; P = 0.21). The mean age was 53 years (SD = 11) and females were 52%. Of 1477 patients included in CCTA yield analysis, patients diagnosed with obstructive coronary artery disease before and after were 15.0% (95% CI 12.6-17.7) and 16.2% (95% CI 13.6-19.1), respectively; mean difference 1.2% (95% CI -2.6 to 5.1; P = 0.53). CONCLUSIONS There was no significant change in the CCTA utilization or yield after the implementation of an education-based HEART pathway in a large academic center. Our findings suggest adopting a more comprehensive approach for deploying such evidence-based protocols to increase institutional compliance.
Collapse
|
54
|
Kargoli F, Levsky J, Bulcha N, Mustehsan MH, Brown-Manhertz D, Furlani A, Polanco D, Mizrachi S, Makkiya M, Golive A, Haramati L, Taub C, Garcia MJ. Comparison Between Anatomical and Functional Imaging Modalities for Evaluation of Chest Pain in the Emergency Department. Am J Cardiol 2020; 125:1809-1814. [PMID: 32345475 DOI: 10.1016/j.amjcard.2020.03.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 03/10/2020] [Accepted: 03/12/2020] [Indexed: 11/30/2022]
Abstract
Evaluation of chest pain in the emergency department (ED) frequently employs a noninvasive strategy, including coronary computed tomography angiography (CCTA), stress echocardiography (SE), or myocardial perfusion imaging (MPI). We sought to report the real-world experience of utilizing CCTA compared with SE and MPI at an urban hospital ED. We conducted a retrospective cohort study of consecutively enrolled patients presenting with chest pain who had normal or nondiagnostic electrocardiogram (ECG), negative initial troponin-T, at least intermediate risk based on modified Diamond-Forrester criteria, and who underwent CCTA, SE, or MPI based on their individual test eligibility criteria. The primary outcome was ED discharge time. Secondary outcomes included test utilization and 30-days rehospitalization rates. The 2,143 patients who were included (mean age was 56 ± 12 years; 55% women) utilization rate (test performed/eligible) was lower for CCTA (n = 354/1,329) and MPI (n = 530/1,435) compared with SE (n = 1,259/1,650), p <0.001. Mean ED discharge times for both CCTA and SE were 12.5 ± 7.4 versus 16 ± 7.3 hours for MPI (p <0.0001). Patients with SE and CCTA were less likely to undergo coronary angiography (29%, 25%, vs 52% for MPI). There was a 1% cardiac-related 30-days rehospitalization rate in the CCTA group versus 1% in SE and 3% in the MPI group (p <0.01). In conclusion, CCTA and SE were associated with faster ED discharge and lower frequency of diagnostic coronary angiography. Notwithstanding its clinical utility, CCTA was underutilized at our large urban ED setting.
Collapse
Affiliation(s)
- Faraj Kargoli
- Department of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York.
| | - Jeffrey Levsky
- Department of Radiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Nurilign Bulcha
- Department of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Mohammad Hashim Mustehsan
- Department of Medicine, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Durline Brown-Manhertz
- Department of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Andrea Furlani
- Department of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Dalvert Polanco
- Department of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Sarah Mizrachi
- Department of Radiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Mohammed Makkiya
- Department of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Anjani Golive
- Department of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Linda Haramati
- Department of Radiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Cynthia Taub
- Department of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| | - Mario J Garcia
- Department of Cardiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York; Department of Radiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
| |
Collapse
|
55
|
Abstract
PURPOSE OF REVIEW The most pertinent clinical question in post-coronary computed tomography angiography (CCTA) patients is the assessment of the physiological significance of an anatomically identified stenosis. The clinical application of radionuclide MPI using single-photon emission computed tomography (SPECT) versus positron emission tomography (PET) in the evaluation and management of patients with an inconclusive CCTA is reviewed using a case-based approach. RECENT FINDINGS Recent evidence suggests that CCTA is the most sensitive non-invasive test to exclude angiographic CAD and may be an effective first-line test especially among symptomatic low-intermediate risk patients. However, in the presence of angiographic atherosclerosis, its specificity and positive predictive value for identifying flow-limiting stenosis are modest. Radionuclide myocardial perfusion imaging offers accurate quantitative assessment of myocardial ischemia, which helps with risk stratification and patient management especially the potential need for revascularization. Routine accurate quantifications of myocardial blood flow and flow reserve are major advantages of PET MPI, which are especially useful when used in patients at intermediate-high clinical risk.
Collapse
Affiliation(s)
- Vasvi Singh
- Cardiovascular Imaging Program, Departments of Radiology and Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Marcelo F Di Carli
- Cardiovascular Imaging Program, Departments of Radiology and Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
- Brigham and Women's Hospital, 75 Francis St, ASB-L1 037C, Boston, MA, 02115, USA.
| |
Collapse
|
56
|
Nieman K. The feasibility, findings and future of CT-FFR in the emergency ward. J Cardiovasc Comput Tomogr 2020; 14:287-288. [DOI: 10.1016/j.jcct.2019.08.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 08/07/2019] [Accepted: 08/19/2019] [Indexed: 10/26/2022]
|
57
|
Siddiqui WJ, Rawala MS, Abid W, Zain M, Sadaf MI, Abbasi D, Alvarez C, Mansoor F, Hasni SF, Aggarwal S. Is Physiologic Stress Test with Imaging Comparable to Anatomic Examination of Coronary Arteries by Coronary Computed Tomography Angiography to Investigate Coronary Artery Disease? - A Systematic Review and Meta-Analysis. Cureus 2020; 12:e6941. [PMID: 32190493 PMCID: PMC7067363 DOI: 10.7759/cureus.6941] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Objective Coronary computed tomography angiography (CCTA) is a noninvasive diagnostic modality that remains underutilized compared to functional stress testing (ST) for investigating coronary artery disease (CAD). Several patients are misdiagnosed with noncardiac chest pain (CP) that eventually die from a cardiovascular event in subsequent years. We compared CCTA to ST to investigate CP. Methods We searched MEDLINE, PubMed, Cochrane Library, and Embase from January 1, 2007 to July 1, 2018 for randomized controlled trials (RCTs) comparing CCTA to ST in patients who presented with acute or stable CP. We used Review Manager (RevMan) [Computer program] Version 5.3 (Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2014) for review and analysis. Results We included 16 RCTs enrolling 21,210 patients; there were more patients with hyperlipidemia and older patients in the ST arm compared to the CCTA arm. There was no difference in mortality: 103 in the CCTA arm vs. 110 in the ST arm (risk ratio [RR] = 0.93, 95% confidence interval [CI] = 0.71-1.21, P = .58, and I2 = 0%). A significant reduction was seen in myocardial infarctions (MIs) after CCTA compared to ST: 115 vs. 156 (RR = 0.71, CI = 0.56-0.91, P < .006, I2=0%). On subgroup analysis, the CCTA arm had fewer MIs vs. the ST with imaging subgroup (RR = 0.70, CI = 0.54-0.89, P = .004, I2 = 0%) and stable CP subgroup (RR = 0.66, CI = 0.50-0.88, P = .004, I2 = 0%). The CCTA arm showed significantly higher invasive coronary angiograms and revascularizations and significantly reduced follow-up testing and recurrent hospital visits. A trend towards increased unstable anginas was seen in the CCTA arm. Conclusions Our analysis showed a significant reduction in downstream MIs, hospital visits, and follow-up testing when CCTA is used to investigate CAD with no difference in mortality.
Collapse
Affiliation(s)
- Waqas J Siddiqui
- Cardiology/Nephrology, Drexel University College of Medicine, Philadelphia, USA
| | | | - Waqas Abid
- Interventional Radiology, Christiana Hospital, Newark, USA
| | - Muhammad Zain
- Internal Medicine, Sheikh Zayed Medical College and Hospital, Rahim Yar Khan, PAK
| | | | - Danish Abbasi
- Cardiovascular Diseases, University of Arkansas, Little Rock, USA
| | | | | | - Syed Farhan Hasni
- Heart Failure and Transplant, Albert Einstein Hospital, Philadelphia, USA
| | | |
Collapse
|
58
|
Stepinska J, Lettino M, Ahrens I, Bueno H, Garcia-Castrillo L, Khoury A, Lancellotti P, Mueller C, Muenzel T, Oleksiak A, Petrino R, Guimenez MR, Zahger D, Vrints CJ, Halvorsen S, de Maria E, Lip GY, Rossini R, Claeys M, Huber K. Diagnosis and risk stratification of chest pain patients in the emergency department: focus on acute coronary syndromes. A position paper of the Acute Cardiovascular Care Association. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2020; 9:76-89. [PMID: 31958018 DOI: 10.1177/2048872619885346] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This paper provides an update on the European Society of Cardiology task force report on the management of chest pain. Its main purpose is to provide an update on the decision algorithms and diagnostic pathways to be used in the emergency department for the assessment and triage of patients with chest pain symptoms suggestive of acute coronary syndromes.
Collapse
Affiliation(s)
- Janina Stepinska
- Department of Intensive Cardiac Therapy, Institute of Cardiology, Poland
| | | | - Ingo Ahrens
- Department of Cardiology and Medical Intensive Care, Augustinerinnen Hospital, Germany
| | - Hector Bueno
- Cardiology Department, Hospital Universitario 12 de Octubre and Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain and Centro Nacional de Investigaciones Cardiovasculares (CNIC), Spain
| | | | - Abdo Khoury
- Department of Emergency Medicine and Critical Care Clinical Investigation Center, University Hospital of Besançon, France
| | | | - Christian Mueller
- Cardiovascular Research Institute, University Hospital of Basel, Switzerland
| | - Thomas Muenzel
- Universitätsmedizin Mainz, Zentrum für Kardiologie, Germany
| | - Anna Oleksiak
- Department of Intensive Cardiac Therapy, Institute of Cardiology, Poland
| | | | | | - Doron Zahger
- Department of Cardiology, Soroka University Medical Center, Israel
| | | | | | | | | | | | | | | |
Collapse
|
59
|
Abordaje invasivo en el síndrome coronario agudo sin elevación del ST. ¿Un enfoque be quick or be dead? Rev Esp Cardiol (Engl Ed) 2020. [DOI: 10.1016/j.recesp.2019.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
60
|
Goehler A, Mayrhofer T, Pursnani A, Ferencik M, Lumish HS, Barth C, Karády J, Chow B, Truong QA, Udelson JE, Fleg JL, Nagurney JT, Gazelle GS, Hoffmann U. Long-term health outcomes and cost-effectiveness of coronary CT angiography in patients with suspicion for acute coronary syndrome. J Cardiovasc Comput Tomogr 2020; 14:44-54. [PMID: 31303580 PMCID: PMC6930365 DOI: 10.1016/j.jcct.2019.06.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 04/11/2019] [Accepted: 06/10/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Randomized trials have shown favorable clinical outcomes for coronary CT angiography (CTA) in patients with suspected acute coronary syndrome (ACS). Our goal was to estimate the cost-effectiveness of coronary CTA as compared to alternative management strategies for ACP patients over lifetime. METHODS Markov microsimulation model was developed to compare cost-effectiveness of competitive strategies for ACP patients: 1) coronary CTA, 2) standard of care (SOC), 3) AHA/ACC Guidelines, and 4) expedited emergency department (ED) discharge protocol with outpatient testing. ROMICAT-II trial was used to populate the model with low to intermediate risk of ACS patient data, whereas diagnostic test-, treatment effect-, morbidity/mortality-, quality of life- and cost data were obtained from the literature. We predicted test utilization, costs, 1-, 3-, 10-year and over lifetime cardiovascular morbidity/mortality for each strategy. We determined quality adjusted life years (QALY) and incremental cost-effectiveness ratio. Observed outcomes in ROMICAT-II were used to validate the short-term model. RESULTS Estimated short-term outcomes accurately reflected observed outcomes in ROMICAT-II as coronary CTA was associated with higher costs ($4,490 vs. $2,513-$4,144) and revascularization rates (5.2% vs. 2.6%-3.7%) compared to alternative strategies. Over lifetime, coronary CTA dominated SOC and ACC/AHA Guidelines and was cost-effective compared to expedited ED protocol ($49,428/QALY). This was driven by lower cardiovascular mortality (coronary CTA vs. expedited discharge: 3-year: 1.04% vs. 1.10-1.17; 10-year: 5.06% vs. 5.21-5.36%; respectively). CONCLUSION Coronary CTA in patients with suspected ACS renders affordable long-term health benefits as compared to alternative strategies.
Collapse
Affiliation(s)
- Alexander Goehler
- Division of Abdominal Imaging and Intervention, Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA; Cardiac MR PET CT Program, Massachusetts General Hospital, Department of Radiology, Boston, MA, USA; Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Thomas Mayrhofer
- Cardiac MR PET CT Program, Massachusetts General Hospital, Department of Radiology, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; School of Business Studies, Stralsund University of Applied Sciences, Stralsund, Germany
| | - Amit Pursnani
- Cardiology Division, Evanston Hospital, Walgreen Building 3rd Floor, 2650, Ridge Ave, Evanston, IL, USA
| | - Maros Ferencik
- Cardiac MR PET CT Program, Massachusetts General Hospital, Department of Radiology, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Knight Cardiovascular Institute, Oregon Health and Science University, 3180, SW Sam Jackson Park Rd., Portland, OR, USA
| | - Heidi S Lumish
- Cardiac MR PET CT Program, Massachusetts General Hospital, Department of Radiology, Boston, MA, USA
| | - Cordula Barth
- Cardiac MR PET CT Program, Massachusetts General Hospital, Department of Radiology, Boston, MA, USA
| | - Júlia Karády
- Cardiac MR PET CT Program, Massachusetts General Hospital, Department of Radiology, Boston, MA, USA; MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Benjamin Chow
- University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Ontario, Canada
| | - Quynh A Truong
- Department of Radiology, New York Presbyterian Hospital and Weill Cornell Medicine, New York, NY, USA
| | - James E Udelson
- Division of Cardiology, Tufts New England Medical Center, Boston, MA, USA
| | - Jerome L Fleg
- National Heart, Lung, and Blood Institute, Bethesda, MD, USA
| | - John T Nagurney
- Harvard Medical School, Boston, MA, USA; Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - G Scott Gazelle
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Department of Health Management and Policy, Harvard School of Public Health, Boston, MA, USA
| | - Udo Hoffmann
- Cardiac MR PET CT Program, Massachusetts General Hospital, Department of Radiology, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
61
|
Sanmartín Fernández M, Abellás Sequeiros M. Invasive management in acute non-ST-segment elevation coronary syndromes: be quick or be dead? REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2020; 73:8-10. [PMID: 31699641 DOI: 10.1016/j.rec.2019.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Accepted: 06/11/2019] [Indexed: 06/10/2023]
|
62
|
Villines D, Summerfelt WT, Spalding JR, Kitt TM, Kristy RM, Houle CR. Use of Initial Noninvasive Cardiac Testing and Association with Downstream Healthcare Resource: A Retrospective Review of Resources Used Across a 12-Month Window for Probable Type I Myocardial Infarction Patients. PHARMACOECONOMICS - OPEN 2019; 3:527-535. [PMID: 31102147 PMCID: PMC6861412 DOI: 10.1007/s41669-019-0128-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
BACKGROUND Clinical guidelines provide clinicians with substantial discretion in the use of noninvasive cardiac testing for patients with suspected coronary artery disease. Repeat testing, frequent emergency department (ED) visits, and increases in other cardiac-related procedures can be a burden on patients and payers and can complicate treatment planning. We assessed downstream healthcare resource utilization (HCRU) for patients undergoing initial single-photon emission computed tomography (SPECT), myocardial perfusion imaging (MPI), stress echocardiography (ECHO), or exercise treadmill testing (ETT) with probable type I myocardial infarction (MI). METHODS Electronic medical records data from 12,130 patients with probable type I MI presenting to EDs within a large healthcare system comprised of 11 adult hospitals were retrospectively analyzed. Logistic and linear regression determined the individual contribution of SPECT-MPI, ETT, and ECHO on repeat cardiovascular (CV) testing, inpatient visits, outpatient visits, and cardiac-related costs within 12 months of the index visit. RESULTS The majority of patients received SPECT-MPI for the index-testing event (56.5%), followed by ETT (29.2%) and ECHO (14.3%). Patients who had SPECT-MPI at the index visit were less likely to have a repeat CV testing visit (odds ratio [OR] 0.77, 95% confidence interval [CI] 0.62‒0.96; p = 0.020) or an inpatient visit (OR 0.70, 95% CI 0.49‒0.98; p = 0.039) than those who underwent ETT or ECHO. ETT and ECHO were not predictive of any outcome. CONCLUSIONS SPECT-MPI does not result in more downstream HCRU than ETT or ECHO and is associated with a lower likelihood of repeat non-invasive CV testing and inpatient visits.
Collapse
Affiliation(s)
- Dana Villines
- Advocate Health Care, 814 W. Nelson St, RM2025, Chicago, IL, 60657, USA.
| | - Wm Thomas Summerfelt
- Advocate Health Care, 814 W. Nelson St, RM2025, Chicago, IL, 60657, USA
- Convergence CT, Chicago, IL, USA
| | | | | | - Rita M Kristy
- Astellas Pharma Global Development, Northbrook, IL, USA
| | | |
Collapse
|
63
|
Coronary Computed Tomography Angiography: Enhancing Risk Stratification and Diagnosis of Cardiovascular Disease in Women. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:62. [DOI: 10.1007/s11936-019-0760-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
|
64
|
Affiliation(s)
- Udo Hoffmann
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Boston, Massachusetts.
| |
Collapse
|
65
|
Chinnaiyan KM, Safian RD, Gallagher ML, George J, Dixon SR, Bilolikar AN, Abbas AE, Shoukfeh M, Brodsky M, Stewart J, Cami E, Forst D, Timmis S, Crile J, Raff GL. Clinical Use of CT-Derived Fractional Flow Reserve in the Emergency Department. JACC Cardiovasc Imaging 2019; 13:452-461. [PMID: 31326487 DOI: 10.1016/j.jcmg.2019.05.025] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 04/30/2019] [Accepted: 05/08/2019] [Indexed: 12/13/2022]
Abstract
OBJECTIVES This study sought to examine the feasibility, safety, clinical outcomes, and costs associated with computed tomography-derived fractional flow reserve (FFRCT) in acute chest pain (ACP) patients in a coronary computed tomography angiography (CTA)-based triage program. BACKGROUND FFRCT is useful in determining lesion-specific ischemia in patients with stable ischemic heart disease, but its utility in ACP has not been studied. METHODS ACP patients with no known coronary artery disease undergoing coronary CTA and coronary CTA with FFRCT were studied. FFRCT ≤0.80 was considered positive for hemodynamically significant stenosis. RESULTS Among 555 patients, 297 underwent coronary CTA and FFRCT (196 negative, 101 positive), whereas 258 had coronary CTA only. The rejection rate for FFRCT was 1.6%. At 90 days, there was no difference in major adverse cardiac events (including death, nonfatal myocardial infarction, and unexpected revascularization after the index visit) between the coronary CTA and FFRCT groups (4.3% vs. 2.7%; p = 0.310). Diagnostic failure, defined as discordance between the coronary CTA or FFRCT results with invasive findings, did not differ between the groups (1.9% vs. 1.68%; p = NS). No deaths or myocardial infarction occurred with negative FFRCT when revascularization was deferred. Negative FFRCT was associated with higher nonobstructive disease on invasive coronary angiography (56.5%) than positive FFRCT (8.0%) and coronary CTA (22.9%) (p < 0.001). There was no difference in overall costs between the coronary CTA and FFRCT groups ($8,582 vs. $8,048; p = 0.550). CONCLUSIONS In ACP, FFRCT is feasible, with no difference in major adverse cardiac events and costs compared with coronary CTA alone. Deferral of revascularization is safe with negative FFRCT, which is associated with higher nonobstructive disease on invasive angiography.
Collapse
Affiliation(s)
| | - Robert D Safian
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, Michigan
| | | | - Julie George
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, Michigan
| | - Simon R Dixon
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, Michigan
| | - Abhay N Bilolikar
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, Michigan
| | - Amr E Abbas
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, Michigan
| | - Mazen Shoukfeh
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, Michigan
| | - Marc Brodsky
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, Michigan
| | - James Stewart
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, Michigan
| | - Elvis Cami
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, Michigan
| | - David Forst
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, Michigan
| | - Steven Timmis
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, Michigan
| | - Jason Crile
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, Michigan
| | - Gilbert L Raff
- Department of Cardiovascular Medicine, Beaumont Health, Royal Oak, Michigan
| |
Collapse
|
66
|
Shaw LJ, Blankstein R, Brown DL, Dhruva SS, Douglas PS, Genders TS, Gibbons RJ, Greenwood JP, Kwong R, Leipsic J, Mahmarian JJ, Maron D, Nagel E, Nicol E, Nieman K, Pellikka PA, Redberg RF, Weir-McCall J, Williams MC, Chandrasekhar Y. Controversies in Diagnostic Imaging of Patients With Suspected Stable and Acute Chest Pain Syndromes. JACC Cardiovasc Imaging 2019; 12:1254-1278. [DOI: 10.1016/j.jcmg.2019.05.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 05/06/2019] [Indexed: 12/21/2022]
|
67
|
Liu T, Yuan X, Wang C, Sun M, Jin S, Dai X. Quantification of plaque characteristics detected by dual source computed tomography angiography to predict myocardial ischemia as assessed by single photon emission computed tomography myocardial perfusion imaging. Quant Imaging Med Surg 2019; 9:711-721. [PMID: 31143662 DOI: 10.21037/qims.2019.04.07] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background We aim to evaluate the relationship between quantitative plaque characteristics detected by dual-source computed tomography angiography (DSCTA) and myocardial ischemia as assessed by single photon emission computed tomography myocardial perfusion imaging (SPECT-MPI). Methods In this study, 460 consecutive patients with suspected coronary artery disease (CAD) underwent DSCTA and stress/rest SPECT-MPI, and 179 patients with coronary artery plaques were quantitatively analyzed. Quantitative coronary artery plaque measurements including total plaque volume, the volume of non-calcified plaque, calcified plaque volume, low-density noncalcified plaque volume, total plaque burden, calcified plaque burden, non-calcified plaque burden, low-density non-calcified plaque (LDNCP) burden, remodeling index, plaque length, maximum diameter stenosis were provided by the automated software (Release 5.6.5, Circle Cardiovascular Imaging, Canada). Univariate and multivariate logistic regression analysis was performed to assess the correlation between quantitative plaque characteristics and myocardial ischemia to determine if plaque characteristics were independent of clinical risk factors and significant CAD. Results One hundred and seventy-nine patients (65% males) with suspected-CAD, undergoing DSCTA and stress/rest SPECT-MPI and single vessel ischemia were considered. There were significant correlations between quantitative assessment of plaque features and myocardial ischemia with details as follow: total plaque volume [25.2 (17.8-37.8) vs. 15.6 (10.3-24.9) mm3, P<0.001], calcified plaque volume (1.6±7.1 vs. 2.3±6.4 mm3, P=0.019), non-calcified plaque volume [23.6 (16.6-35.9) vs. 14.6 (10.3-22.8) mm3, P<0.001)], LDNCP volume [4.9 (2.1-8.2) vs. 2.2 (1.0-5.5) mm3, P=0.003], total plaque burden (47.6%±17.1% vs. 36.2%±17.3%, P=0.002), calcified plaque burden (1.5%±5.5% vs. 2.9%±6.9%, P=0.014), non-calcified plaque burden (46.1%±18.8% vs. 33.3%±16.4%, P=0.001), LDNCP burden [12.3% (6.4-17.7) vs. 3.3% (1.6-5.3), P<0.001], remodeling index [1.2 (1.1-1.4) vs. 1.0 (1.1-1.2), P<0.001], plaque length [4.0 (3.2-6.1) vs. 3.3 (2.8-3.8) mm, P=0.009], maximum diameter stenosis [18.1% (10.0-52.9) vs. 12.9% (6.5-18.5), P=0.011]. In a multivariate analysis, low-density noncalcified plaque burden (OR 1.33; 95% CI, 1.16-1.53, P<0.001) remained a significant predictor of myocardial ischemia after adjusting for stenosis ≥50% and gender. The area under curve (AUC) of the model containing LDNCP burden, stenosis ≥50% and gender was 0.875 (95% CI, 0.812-0.938), which was significantly better than the model with stenosis ≥50% and gender (AUC 0.729; 95% CI, 0.633-0.825). Conclusions Quantitative plaque characteristics detected by DSCTA are independently correlated with the incidence of myocardial ischemia by SPECT-MPI in patients with suspected CAD.
Collapse
Affiliation(s)
- Ting Liu
- Department of Radiology, First Affiliated Hospital of China Medical University, Shenyang 110001, China
| | - Xue Yuan
- Department of Radiology, First Affiliated Hospital of China Medical University, Shenyang 110001, China
| | - Congcong Wang
- Department of Radiology, First Affiliated Hospital of China Medical University, Shenyang 110001, China
| | - Mingfei Sun
- Department of Radiology, First Affiliated Hospital of China Medical University, Shenyang 110001, China
| | - Shiqi Jin
- Department of Radiology, First Affiliated Hospital of China Medical University, Shenyang 110001, China
| | - Xu Dai
- Department of Radiology, First Affiliated Hospital of China Medical University, Shenyang 110001, China
| |
Collapse
|
68
|
Litwin SE, Coles A, Pagidipati N, Lee KL, Pellikka PA, Mark DB, Udelson JE, Hoffmann U, Douglas PS. Effects of obesity on noninvasive test results in patients with suspected cardiac ischemia: Insights from the PROMISE trial. J Cardiovasc Comput Tomogr 2019; 13:211-218. [PMID: 30954400 DOI: 10.1016/j.jcct.2019.03.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 02/21/2019] [Accepted: 03/25/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Obesity is a risk factor for coronary artery disease (CAD), but adiposity may mimic symptoms of CAD and reduce the accuracy of diagnostic testing. METHODS Patients from the PROMISE trial (n = 8889) were classified according to body mass index (BMI). We assessed relationships between BMI, physician's preference of functional test, test positivity, and results of invasive coronary angiography (Cath) using logistic regression models. RESULTS Nearly half (48%) of the patients had BMI ≥ 30 kg/m2, and 20% had BMI ≥ 35. Providers were more likely to prefer nuclear myocardial perfusion imaging (MPI) over other functional tests as BMI increased. The rate of test positivity with coronary computed tomographic angiography (CTA) was not different (10% vs. 12%) in patients with BMI ≥35 vs. < 35. The same was true for stress echocardiogram and stress electrocardiogram (positivity 8-13%, P > 0.8 for both). In contrast, MPI was significantly more likely to be positive in those with BMI ≥35 vs. <35 (18% vs. 13%; P = 0.001). The likelihood of obstructive CAD at Cath did not differ with BMI ≥35 vs. <35 in patients having CTA (52% vs. 59%, P = 0.22), but among MPI patients, Cath positivity was only 29% with BMI ≥35 vs. 48% with BMI <35 (P = 0.005). Radiation exposure increased with higher BMI in both MPI and CTA groups. CONCLUSIONS Increasing levels of obesity adversely affect the diagnostic yield of MPI more than CTA. The degree of obesity should be considered when choosing evaluation strategies for patients with chest pain. CLINICAL TRIAL REGISTRATION PROMISE ClinicalTrials.gov number, NCT01174550.
Collapse
Affiliation(s)
- Sheldon E Litwin
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA.
| | - Adrian Coles
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA.
| | - Neha Pagidipati
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA; Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
| | - Kerry L Lee
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA.
| | | | - Daniel B Mark
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA; Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
| | - James E Udelson
- Department of Medicine, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA.
| | - Udo Hoffmann
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Pamela S Douglas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA; Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
| | | |
Collapse
|
69
|
Tzolos E, Newby DE. Coronary Computed Tomography Angiography Improving Outcomes in Patients with Chest Pain. CURRENT CARDIOVASCULAR IMAGING REPORTS 2019; 12:15. [PMID: 33442442 PMCID: PMC7116579 DOI: 10.1007/s12410-019-9492-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Purpose of Review To provide an overview of recent studies of coronary computed tomography angiography (CCTA) and how it has helped to improve clinical outcomes for patients presenting with chest pain. Recent Findings Randomised controlled trials have uniformly demonstrated that the use of CCTA is associated with improvements in patient diagnosis, management and treatments as well as the avoidance of unnecessary invasive coronary angiography. These changes have been associated with consistent reductions in long-term rates of fatal or non-fatal myocardial infarction. Summary Major beneficial effects in clinical management and patient outcomes are seen with the use of coronary computed tomography angiography. CCTA might be considered to be the first test of choice for the investigation of coronary heart disease.
Collapse
Affiliation(s)
- Evangelos Tzolos
- British Heart Foundation, Centre for Cardiovascular Science, University of Edinburgh, Chancellor’s Building, Edinburgh EH16 4SA, Scotland, UK
| | - David E. Newby
- British Heart Foundation, Centre for Cardiovascular Science, University of Edinburgh, Chancellor’s Building, Edinburgh EH16 4SA, Scotland, UK
| |
Collapse
|
70
|
Coronary computed tomographic imaging in women: An expert consensus statement from the Society of Cardiovascular Computed Tomography. J Cardiovasc Comput Tomogr 2018; 12:451-466. [DOI: 10.1016/j.jcct.2018.10.019] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 10/21/2018] [Indexed: 12/21/2022]
|
71
|
Risk stratification and role for additional diagnostic testing in patients with acute chest pain and normal high-sensitivity cardiac troponin levels. PLoS One 2018; 13:e0203506. [PMID: 30192899 PMCID: PMC6128560 DOI: 10.1371/journal.pone.0203506] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 08/20/2018] [Indexed: 12/27/2022] Open
Abstract
Background Normal high sensitivity cardiac troponin (hs-cTn) assays rule out acute myocardial infarction (AMI) with great accuracy, but additional non-invasive testing is frequently ordered. This observational study evaluates whether clinical characteristics can contribute to risk stratification and could guide referral for additional testing. Methods 918 serial patients with acute chest pain and normal hs-cTnT levels were prospectively included. Major adverse cardiac events (MACE) and non-invasive test results were assessed during one-year follow-up. Patients were classified as low and high risk based on clinical characteristics. Results MACE occurred in 6.1% of patients and mainly comprised revascularizations (86%). A recent abnormal stress test, suspicious history, a positive family history and higher baseline hs-cTnT levels were independent predictors of MACE with odds ratios of 16.00 (95%CI:6.25–40.96), 16.43 (6.36–42.45), 2.33 (1.22–4.42) and 1.10 (1.01–1.21), respectively. Absence of both recent abnormal stress test and suspicious history identified 86% of patients. These patients were at very low risk for MACE (0.4% in 30-days and 2.3% in one-year). Despite this, the majority (287/345 = 83%) of additional tests were performed in low risk patients, with <10% abnormal test findings. The diagnostic yield was significantly higher in the remaining higher risk patients, 40% abnormal test findings and a positive predictive value of 70% for MACE. Similar results were observed in patients without known coronary artery disease. Conclusions Clinical characteristics can be used to identify low risk patients with acute chest pain and normal hs-cTnT levels. Current strategies in the emergency department result in numerous additional tests, which are mostly ordered in patients at very low risk and have a low diagnostic yield.
Collapse
|
72
|
Li YH, Wang YC, Wang YC, Liu JC, Lee CH, Chen CC, Hsieh IC, Kuo FY, Huang WC, Sung SH, Chiu CZ, Hsu JC, Jen SL, Hwang JJ, Lin JL. 2018 Guidelines of the Taiwan Society of Cardiology, Taiwan Society of Emergency Medicine and Taiwan Society of Cardiovascular Interventions for the management of non ST-segment elevation acute coronary syndrome. J Formos Med Assoc 2018; 117:766-790. [PMID: 30017533 DOI: 10.1016/j.jfma.2018.06.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 05/25/2018] [Accepted: 06/01/2018] [Indexed: 12/11/2022] Open
Abstract
In Taiwan, the incidence of non-ST segment elevation acute coronary syndrome (NSTE-ACS) continues to increase in recent years. The purpose of this guideline is to help health care professionals in Taiwan to use adequate tests and treatments for management of NSTE-ACS. For rapid diagnosis, in addition to history and physical examination, 0/3 h rapid diagnosis protocol with high sensitivity cardiac troponin assay is recommended in this guideline. Dual antiplatelet and anticoagulation therapies are important parts in the initial treatment. Risk stratification should be performed to identify high risk patients for early coronary angiography. Through evaluation of the coronary anatomy and other clinical factors, the decision for coronary revascularization, either by percutaneous coronary intervention or coronary artery bypass grafting, should be decided by the heart team. The duration of dual antiplatelet therapy should be given for at least 12 months after discharge. Other secondary preventive medications are also recommended for long term use.
Collapse
Affiliation(s)
- Yi-Heng Li
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Yu-Chen Wang
- Division of Cardiology, Department of Internal Medicine, Asia University Hospital, Taichung, Taiwan; Department of Biotechnology, Asia University, Taichung, Taiwan; Division of Cardiology, Department of Internal Medicine, China Medical University College of Medicine and Hospital, Taichung, Taiwan
| | - Yi-Chih Wang
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
| | - Ju-Chi Liu
- Division of Cardiovascular Medicine, Department of Internal Medicine, Shuang Ho Hospital and Taipei Medical University, New Taipei City, Taiwan
| | - Cheng-Han Lee
- Department of Internal Medicine and Institute of Clinical Pharmacy and Pharmaceutical Sciences, National Cheng Kung University Hospital and College of Medicine, Tainan, Taiwan
| | - Chun-Chi Chen
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - I-Chang Hsieh
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Taoyuan, Taiwan
| | - Feng-You Kuo
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung and School of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Wei-Chun Huang
- Division of Cardiology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung and School of Medicine, National Yang Ming University, Taipei, Taiwan
| | - Shih-Hsien Sung
- Department of Medicine, Taipei Veterans General Hospital and National Yang Ming University, Taipei, Taiwan
| | - Chiung-Zuan Chiu
- Division of Cardiology, Shin-Kong Wu Ho Su Memorial Hospital, Taipei, Taiwan; School of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Jung-Cheng Hsu
- Cardiology Division of Cardiovascular Medical Center, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Shu-Long Jen
- Heart Center, Cheng Hsin General Hospital, Taipei, Taiwan
| | - Juey-Jen Hwang
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan.
| | - Jiunn-Lee Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan; Division of Cardiovascular Medicine, Department of Internal Medicine, Shuang Ho Hospital and Taipei Medical University, New Taipei City, Taiwan.
| | | |
Collapse
|
73
|
Burghard P, Plank F, Beyer C, Müller S, Dörler J, Zaruba MM, Pölzl L, Pölzl G, Klauser A, Rauch S, Barbieri F, Langer CE, Schgoer W, Williamson EE, Feuchtner G. Evaluation of right ventricular function by coronary computed tomography angiography using a novel automated 3D right ventricle volume segmentation approach: a validation study. Eur Radiol 2018; 28:5129-5136. [PMID: 29869175 DOI: 10.1007/s00330-018-5523-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Revised: 04/25/2018] [Accepted: 05/03/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To evaluate right ventricle (RV) function by coronary computed tomography angiography (CTA) using a novel automated three-dimensional (3D) RV volume segmentation tool in comparison with clinical reference modalities. METHODS Twenty-six patients with severe end-stage heart failure [left ventricle (LV) ejection fraction (EF) <35%] referred to CTA were enrolled. A specific individually tailored biphasic contrast agent injection protocol was designed (80%/20% high/low flow) was designed. Measurement of RV function [EF, end-diastolic volume (EDV), end-systolic volume (ESV)] by CTA was compared with tricuspid annular plane systolic excursion (TAPSE) by transthoracic echocardiography (TTE) and right heart invasive catheterisation (IC). RESULTS Automated 3D RV volume segmentation was successful in 26 (100%) patients. Read-out time was 3 min 33 s (range, 1 min 50s-4 min 33s). RV EF by CTA was stronger correlated with right atrial pressure (RAP) by IC (r = -0.595; p = 0.006) but weaker with TAPSE (r = 0.366, p = 0.94). When comparing TAPSE with RAP by IC (r = -0.317, p = 0.231), a weak-to-moderate non-significant inverse correlation was found. Interobserver correlation was high with r = 0.96 (p < 0.001), r = 0.86 (p < 0.001) and r = 0.72 (p = 0.001) for RV EDV, ESV and EF, respectively. CT attenuation of the right atrium (RA) and right ventricle (RV) was 196.9 ± 75.3 and 217.5 ± 76.1 HU, respectively. CONCLUSIONS Measurement of RV function by CTA using a novel 3D volumetric segmentation tool is fast and reliable by applying a dedicated biphasic injection protocol. The RV EF from CTA is a closer surrogate of RAP than TAPSE by TTE. KEY POINTS • Evaluation of RV function by cardiac CTA by using a novel 3D volume segmentation tool is fast and reliable. • A biphasic contrast agent injection protocol ensures homogenous RV contrast attenuation. • Cardiac CT is a valuable alternative modality to CMR for the evaluation of RV function.
Collapse
Affiliation(s)
- Philipp Burghard
- Department of Radiology, Innsbruck Medical University, Anichstrasse 35, 6020, Innsbruck, Austria. .,, Breitenwangerstrasse 19, 6600, Reutte, Austria.
| | - Fabian Plank
- Department of Internal Medicine III, Innsbruck Medical University, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Christoph Beyer
- Department of Radiology, Innsbruck Medical University, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Silvana Müller
- Department of Internal Medicine III, Innsbruck Medical University, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Jakob Dörler
- Department of Internal Medicine III, Innsbruck Medical University, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Marc-Michael Zaruba
- Department of Internal Medicine III, Innsbruck Medical University, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Leo Pölzl
- Department of Internal Medicine III, Innsbruck Medical University, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Gerhard Pölzl
- Department of Internal Medicine III, Innsbruck Medical University, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Andrea Klauser
- Department of Radiology, Innsbruck Medical University, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Stefan Rauch
- Department of Radiology, Innsbruck Medical University, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Fabian Barbieri
- Department of Internal Medicine III, Innsbruck Medical University, Anichstrasse 35, 6020, Innsbruck, Austria
| | | | - Wilfried Schgoer
- Department of Internal Medicine III, Innsbruck Medical University, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Eric E Williamson
- Department of Radiology, Mayo Clinic Rochester, Minnesota, 200 1st St SW, Rochester, MN, 55902, USA
| | - Gudrun Feuchtner
- Department of Radiology, Innsbruck Medical University, Anichstrasse 35, 6020, Innsbruck, Austria
| |
Collapse
|
74
|
Abd alamir M, Noack P, Jang KH, Moore JA, Goldberg R, Poon M. Computer-aided analysis of 64- and 320-slice coronary computed tomography angiography: a comparison with expert human interpretation. Int J Cardiovasc Imaging 2018; 34:1473-1483. [DOI: 10.1007/s10554-018-1361-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 04/20/2018] [Indexed: 10/17/2022]
|
75
|
Abstract
PURPOSE OF REVIEW To compare outcomes between registries and randomized controlled trials of coronary computed tomographic angiography (CCTA)-based versus standard of care approaches to the initial evaluation of patients with acute chest pain. RECENT FINDINGS Randomized trials have demonstrated CCTA to be a safe and efficient tool for triage of low- to intermediate-risk patients presenting to the emergency department with chest pain. Recent studies demonstrate heterogeneous result using different standard of care approaches for evaluation of hard endpoints in comparison with standard evaluation. Also, there has been continued concern for increase in subsequent testing after coronary CTA. Although CCTA improves detection of coronary artery disease, it is uncertain if it will bring improvement of long-term health outcomes at this point of time. Careful analysis of the previous results and further investigation will be required to validate evaluation of hard endpoints.
Collapse
|
76
|
Coronary CT Angiography: Use in Patients With Chest Pain Presenting to Emergency Departments. AJR Am J Roentgenol 2018; 210:816-820. [PMID: 29446681 DOI: 10.2214/ajr.17.18740] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Previously published reports have shown that coronary CT angiography (CCTA) is a more efficient method of diagnosis than myocardial perfusion imaging (MPI) and stress echocardiography for patients presenting to emergency departments (EDs) with acute chest pain. In light of this evidence, the objective of this study was to examine recent trends in the use of these techniques in EDs. MATERIALS AND METHODS The nationwide Medicare Part B databases for 2006-2015 were the data source. The Current Procedural Terminology, version 4, codes for CCTA, MPI, and stress echocardiography were selected. Medicare place-of-service codes were used to determine procedure volumes in EDs. Medicare specialty codes were used to ascertain how many of these examinations were interpreted by radiologists, cardiologists, and other physicians as a group. RESULTS From 2006 to 2015, there was essentially no change in the number of MPI examinations performed in EDs for patients using Medicare (22,342 in 2006, 22,338 in 2015) or in the number of stress echocardiograms (3544 in 2006, 3520 in 2015). By contrast, the number of CCTA examinations increased rapidly, from 126 in 2006 to 1919 in 2015 (compound annual growth rate, 35%). Despite this rapid growth, patients in EDs underwent 11.6 times as many MPI as CCTA examinations in 2015. In that last year of the study, radiologists interpreted 78% of ED MPI and 83% of ED CCTA examinations. CONCLUSION Use of CCTA in EDs has increased rapidly, but far more MPI examinations are still being performed. This finding suggests that recently acquired evidence is not yet being fully acted upon.
Collapse
|
77
|
Immediate Stress Echocardiography for Low-Risk Chest Pain Patients in the Emergency Department: A Prospective Observational Cohort Study. J Emerg Med 2017; 54:156-164. [PMID: 29274930 DOI: 10.1016/j.jemermed.2017.10.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2017] [Revised: 10/06/2017] [Accepted: 10/26/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND Evaluation and disposition of low-risk chest pain (CP) patients in the emergency department (ED) is time consuming and expensive. Low-risk CP often results in hospital admission to rule out myocardial infarction, which leads to additional costs and delays. OBJECTIVE Our aim was to assess whether an immediate exercise stress echocardiogram (IESE) in the ED will allow safe, efficient, and cost-effective evaluation and discharge of patients with low-risk CP. METHODS Low-risk CP patients (TIMI [Thrombolysis in Myocardial Infarction] score 0-1) presenting to the ED with normal electrocardiogram, no history of coronary artery disease, and negative troponin T received IESE. We followed these patients for major adverse cardiac events and compared them to a control cohort of similar-risk patients admitted with traditional care at 1 and 6 months. RESULTS We enrolled 216 patients, 117 IESE and 109 control. We obtained follow-up at 1 and 6 months in 94% of the IESE group and 88% in the control group. There was no difference in diagnostic catheterization or percutaneous coronary intervention between the 2 groups (6.0% and 1.7% vs. 6.4% and 1.8%; p = 0.89). Median time from triage to discharge was significantly shorter with IESE (572.6 min vs. 1466.0 min), resulting in significantly lower cost ($4380.50 vs. $6191.70). There were no adverse events related to IESE or early discharge. CONCLUSIONS In our study, IESE for low-risk CP patients presenting to the ED has the potential to be equally safe, more expeditious, and more cost effective than admission to an observation unit.
Collapse
|
78
|
Shaw LJ, Blankstein R, Jacobs JE, Leipsic JA, Kwong RY, Taqueti VR, Beanlands RSB, Mieres JH, Flamm SD, Gerber TC, Spertus J, Di Carli MF. Defining Quality in Cardiovascular Imaging: A Scientific Statement From the American Heart Association. Circ Cardiovasc Imaging 2017; 10:e000017. [PMID: 29242239 PMCID: PMC5926771 DOI: 10.1161/hci.0000000000000017] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The aims of the current statement are to refine the definition of quality in cardiovascular imaging and to propose novel methodological approaches to inform the demonstration of quality in imaging in future clinical trials and registries. We propose defining quality in cardiovascular imaging using an analytical framework put forth by the Institute of Medicine whereby quality was defined as testing being safe, effective, patient-centered, timely, equitable, and efficient. The implications of each of these components of quality health care are as essential for cardiovascular imaging as they are for other areas within health care. Our proposed statement may serve as the foundation for integrating these quality indicators into establishing designations of quality laboratory practices and developing standards for value-based payment reform for imaging services. We also include recommendations for future clinical research to fulfill quality aims within cardiovascular imaging, including clinical hypotheses of improving patient outcomes, the importance of health status as an end point, and deferred testing options. Future research should evolve to define novel methods optimized for the role of cardiovascular imaging for detecting disease and guiding treatment and to demonstrate the role of cardiovascular imaging in facilitating healthcare quality.
Collapse
|
79
|
DeLaney MC, Neth M, Thomas JJ. Chest pain triage: Current trends in the emergency departments in the United States. J Nucl Cardiol 2017; 24:2004-2011. [PMID: 27638744 DOI: 10.1007/s12350-016-0578-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2016] [Accepted: 05/05/2016] [Indexed: 11/26/2022]
Abstract
Chest pain is one of the most common complaints in the emergency department (ED). Over the past decade, there has been a significant shift in the approach to patients with chest pain in the ED. With the development of improved cardiac biomarkers, the validation of clinical scoring systems, and an increasing emphasis on shared patient medical decision making, increasing numbers of patients in the ED are being evaluated without requiring admission to the hospital.
Collapse
Affiliation(s)
- Matthew C DeLaney
- Department of Emergency Medicine, University of Alabama at Birmingham, 619 19th St. S., Birmingham, AL, 35233, USA.
| | - Matthew Neth
- Department of Emergency Medicine, University of Alabama at Birmingham, 619 19th St. S., Birmingham, AL, 35233, USA
| | - Jared J Thomas
- Department of Emergency Medicine, University of Alabama at Birmingham, 619 19th St. S., Birmingham, AL, 35233, USA
| |
Collapse
|
80
|
Abstract
Acute chest pain is a leading cause of Emergency Department visits. Computed tomography angiography plays a vital diagnostic role in such cases, but there are several common challenges associated with the imaging of acute chest pain, which, if unrecognized, can lead to an inconclusive or incorrect diagnosis. These imaging challenges fall broadly into 3 categories: (1) image acquisition, (2) image interpretation (including physiological and pathologic mimics), and (3) result communication. The aims of this review are to describe and illustrate the most common challenges in the imaging of acute chest pain and to provide solutions that will facilitate accurate diagnosis of the causes of acute chest pain in the emergency setting.
Collapse
|
81
|
Maaniitty T, Stenström I, Bax JJ, Uusitalo V, Ukkonen H, Kajander S, Mäki M, Saraste A, Knuuti J. Prognostic Value of Coronary CT Angiography With Selective PET Perfusion Imaging in Coronary Artery Disease. JACC Cardiovasc Imaging 2017; 10:1361-1370. [DOI: 10.1016/j.jcmg.2016.10.025] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 10/21/2016] [Accepted: 10/27/2016] [Indexed: 10/19/2022]
|
82
|
Foy AJ, Dhruva SS, Peterson B, Mandrola JM, Morgan DJ, Redberg RF. Coronary Computed Tomography Angiography vs Functional Stress Testing for Patients With Suspected Coronary Artery Disease: A Systematic Review and Meta-analysis. JAMA Intern Med 2017; 177:1623-1631. [PMID: 28973101 PMCID: PMC5710269 DOI: 10.1001/jamainternmed.2017.4772] [Citation(s) in RCA: 104] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Accepted: 07/03/2017] [Indexed: 12/13/2022]
Abstract
Importance Coronary computed tomography angiography (CCTA) is a new approach for the diagnosis of anatomical coronary artery disease (CAD), but it is unclear how CCTA performs compared with the standard approach of functional stress testing. Objective To compare the clinical effectiveness of CCTA with that of functional stress testing for patients with suspected CAD. Data Sources A systematic literature search was conducted in PubMed and MEDLINE for English-language randomized clinical trials of CCTA published from January 1, 2000, to July 10, 2016. Study Selection Researchers selected randomized clinical trials that compared a primary strategy of CCTA with that of functional stress testing for patients with suspected CAD and reported data on patient clinical events and changes in therapy. Data Extraction and Synthesis Two reviewers independently extracted data from and assessed the quality of the trials. This analysis followed the PRISMA statement for reporting systematic reviews and meta-analyses and used the Cochrane Collaboration's tool for assessing risk of bias in randomized trials. The Mantel-Haenszel method was used to conduct the primary analysis. Summary relative risks were calculated with a random-effects model. Main Outcomes and Measures The outcomes of interest were all-cause mortality, cardiac hospitalization, myocardial infarction, invasive coronary angiography, coronary revascularization, new CAD diagnoses, and change in prescription for aspirin and statins. Results Thirteen trials were included, with 10 315 patients in the CCTA arm and 9777 patients in the functional stress testing arm who were followed up for a mean duration of 18 months. There were no statistically significant differences between CCTA and functional stress testing in death (1.0% vs 1.1%; risk ratio [RR], 0.93; 95% CI, 0.71-1.21) or cardiac hospitalization (2.7% vs 2.7%; RR, 0.98; 95% CI, 0.79-1.21), but CCTA was associated with a reduction in the incidence of myocardial infarction (0.7% vs 1.1%; RR, 0.71; 95% CI, 0.53-0.96). Patients undergoing CCTA were significantly more likely to undergo invasive coronary angiography (11.7% vs 9.1%; RR, 1.33; 95% CI, 1.12-1.59) and revascularization (7.2% vs 4.5%; RR, 1.86; 95% CI, 1.43-2.43). They were also more likely to receive a diagnosis of new CAD and to have initiated aspirin or statin therapy. Conclusions and Relevance Compared with functional stress testing, CCTA is associated with a reduced incidence of myocardial infarction but an increased incidence of invasive coronary angiography, revascularization, CAD diagnoses, and new prescriptions for aspirin and statins. Despite these differences, CCTA is not associated with a reduction in mortality or cardiac hospitalizations.
Collapse
Affiliation(s)
- Andrew J. Foy
- Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Sanket S. Dhruva
- Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Brandon Peterson
- Department of Medicine, Penn State College of Medicine, Hershey, Pennsylvania
| | - John M. Mandrola
- Louisville Cardiology Group, Baptist Health, Louisville, Kentucky
| | - Daniel J. Morgan
- Department of Medicine, University of Maryland School of Medicine, Baltimore
| | - Rita F. Redberg
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
- Editor, JAMA Internal Medicine
| |
Collapse
|
83
|
Cullen L, Greenslade JH, Hawkins T, Hammett C, O'Kane S, Ryan K, Parker K, Schluter J, Dalton E, Brown AF, Than M, Peacock WF, Jaffe A, O'Rourke PK, Parsonage WA. Improved Assessment of Chest pain Trial (IMPACT): assessing patients with possible acute coronary syndromes. Med J Aust 2017; 207:195-200. [PMID: 28987132 DOI: 10.5694/mja16.01351] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 03/21/2017] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To examine the safety and efficacy of the Improved Assessment of Chest pain Trial (IMPACT) protocol, a strategy for accelerated assessment of patients presenting to emergency departments (EDs) with chest pain. DESIGN, SETTING AND PARTICIPANTS IMPACT was an intervention trial at a single tertiary referral hospital (Royal Brisbane and Women's Hospital) during February 2011 - March 2014. 1366 prospectively recruited patients presenting to the ED with symptoms of suspected acute coronary syndrome (ACS) were stratified into groups at low, intermediate or high risk of an ACS. INTERVENTION High risk patients were treated according to NHFA/CSANZ guidelines. Low and intermediate risk patients underwent troponin testing (sensitive assay) 0 and 2 hours after presentation. Intermediate risk patients underwent objective testing after the second troponin test; low risk patients were discharged without further objective testing. MAIN OUTCOME MEASURES The primary outcome was an ACS within 30 days of presentation. Secondary outcomes were ED and hospital lengths of stay (LOS). RESULTS The IMPACT protocol stratified 244 (17.9%) patients to low risk, 789 (57.7%) to intermediate risk, and 333 (24.4%) to high risk categories. The overall 30-day ACS rate was 6.6%, but there were no ACS events in the low risk group, and 14 (1.8%) in the intermediate risk group. The median hospital LOS was 5.1 hours (IQR, 4.2-5.6 h) for low risk and 7.7 hours (IQR, 6.1-21 h) for intermediate risk patients. CONCLUSIONS The IMPACT protocol safely and efficiently allowed a large proportion of patients presenting to EDs with chest pain to undergo accelerated assessment for risk of an ACS. CLINICAL TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12611000206921.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Kate Parker
- Royal Brisbane and Women's Hospital, Brisbane, QLD
| | | | - Emily Dalton
- Royal Brisbane and Women's Hospital, Brisbane, QLD
| | | | - Martin Than
- Christchurch Hospital, Christchurch, New Zealand
| | - W Frank Peacock
- Baylor College of Medicine, Houston, TX, United States of America
| | - Allan Jaffe
- Mayo Clinic, Rochester, MN, United States of America
| | | | | |
Collapse
|
84
|
Bamberg F, Mayrhofer T, Ferencik M, Bittner DO, Hallett TR, Janjua S, Schlett CL, Nagurney JT, Udelson JE, Truong QA, Woodard PK, Hollander JE, Litt H, Hoffmann U. Age- and sex-based resource utilisation and costs in patients with acute chest pain undergoing cardiac CT angiography: pooled evidence from ROMICAT II and ACRIN-PA trials. Eur Radiol 2017; 28:851-860. [PMID: 28875364 DOI: 10.1007/s00330-017-4981-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 06/16/2017] [Accepted: 07/10/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To determine resource utilisation according to age and gender-specific subgroups in two large randomized diagnostic trials. METHODS We pooled patient-specific data from ACRIN-PA 4005 and ROMICAT II that enrolled subjects with acute chest pain at 14 US sites. Subjects were randomized between a standard work-up and a pathway utilizing cardiac computed tomography angiography (CCTA) and followed for the occurrence of acute coronary syndrome (ACS) and resource utilisation during index hospitalisation and 1-month follow-up. Study endpoints included diagnostic accuracy of CCTA for the detection of ACS as well as resource utilisation. RESULTS Among 1240 patients who underwent CCTA, negative predictive value of CCTA to rule out ACS remained very high (≥99.4%). The proportion of patients undergoing additional diagnostic testing and cost increased with age for both sexes (p < 0.001), and was higher in men as compared to women older than 60 years (43.1% vs. 23.4% and $4559 ± 3382 vs. $3179 ± 2562, p < 0.01; respectively). Cost to rule out ACS was higher in men (p < 0.001) and significantly higher for patients older than 60 years ($2860-5935 in men, p < 0.001). CONCLUSIONS CCTA strategy in patients with acute chest pain results in varying resource utilisation according to age and gender-specific subgroups, mandating improved selection for advanced imaging. KEY POINTS • In this analysis, CAD and ACS increased with age and male gender. • CCTA in patients with acute chest pain results in varying resource utilisation. • Significant increase of diagnostic testing and cost with age for both sexes. • Cost to rule out ACS is higher in men and patients >60 years. • Improved selection of subjects for cardiac CTA result in more resource-driven implementation.
Collapse
Affiliation(s)
- Fabian Bamberg
- Cardiac MR PET CT Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
- Department of Diagnostic and Interventional Radiology, University of Tuebingen, Hoppe-Seyler-Str. 3, 72076, Tuebingen, Germany.
| | - Thomas Mayrhofer
- Cardiac MR PET CT Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- School of Business Studies, Stralsund University of Applied Science, Stralsund, Germany
| | - Maros Ferencik
- Cardiac MR PET CT Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR, USA
| | - Daniel O Bittner
- Cardiac MR PET CT Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Medicine 2 - Cardiology, Friedrich-Alexander University Erlangen-Nürnberg (FAU), University Hospital Erlangen, Erlangen, Germany
| | - Travis R Hallett
- Cardiac MR PET CT Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sumbal Janjua
- Cardiac MR PET CT Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher L Schlett
- Cardiac MR PET CT Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - John T Nagurney
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - James E Udelson
- Division of Cardiology and the Cardio-Vascular Center, Tufts Medical Center, Boston, MA, USA
| | | | - Pamela K Woodard
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Judd E Hollander
- Department of Emergency Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Harold Litt
- Department of Radiology and Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Udo Hoffmann
- Cardiac MR PET CT Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Diagnostic and Interventional Radiology, University of Tuebingen, Hoppe-Seyler-Str. 3, 72076, Tuebingen, Germany
| |
Collapse
|
85
|
Healthcare Policy Statement on the Utility of Coronary Computed Tomography for Evaluation of Cardiovascular Conditions and Preventive Healthcare: From the Health Policy Working Group of the Society of Cardiovascular Computed Tomography. J Cardiovasc Comput Tomogr 2017; 11:404-414. [DOI: 10.1016/j.jcct.2017.08.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 08/14/2017] [Accepted: 08/14/2017] [Indexed: 12/14/2022]
|
86
|
Gongora CA, Bavishi C, Uretsky S, Argulian E. Acute chest pain evaluation using coronary computed tomography angiography compared with standard of care: a meta-analysis of randomised clinical trials. Heart 2017; 104:215-221. [DOI: 10.1136/heartjnl-2017-311647] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 06/26/2017] [Accepted: 07/07/2017] [Indexed: 11/04/2022] Open
Abstract
ObjectiveCoronary CT angiography (CCTA) has certain advantages compared with stress testing including greater accuracy in identifying obstructive coronary disease. The aim of the study was to perform a systematical review and meta-analysis comparing CCTA with other standard-of-care (SOC) approaches in evaluation of patients with acute chest pain.MethodsElectronic databases were systematically searched to identify randomised clinical trials of patients with acute chest pain comparing CCTA with SOC approaches. We examined the following end points: mortality, major adverse cardiac events (MACE), myocardial infarction (MI), invasive coronary angiography (ICA) and revascularisation. Pooled risk ratios (RR) and their 95% CIs were calculated using random-effects models.ResultsTen trials with 6285 patients were included. The trials used different definitions and implementation for SOC but all used physiologic testing. The clinical follow-up ranged from 1 to 19 months. There were no significant differences in all-cause mortality (RR 0.48, 95% CI 0.17 to 1.36, p=0.17), MI (RR 0.82, 95% CI 0.49 to 1.39, p=0.47) or MACE (RR 0.98, 95% CI 0.67 to 1.43, p=0.92) between the groups. However, significantly higher rates of ICA (RR 1.32, 95% CI 1.07 to 1.63, p=0.01) and revascularisation (RR 1.77, 95% CI 1.35 to 2.31, p<0.0001) were observed in the CCTA arm.ConclusionsCompared with other SOC approaches use of CCTA is associated with similar major adverse cardiac events but higher rates of revascularisation in patients with acute chest pain.
Collapse
|
87
|
Sigurdsson G. Improved Precision of Initial Chest Pain Evaluation With Fractional Flow Reserve Computed Tomography. J Am Heart Assoc 2017; 6:JAHA.117.006835. [PMID: 28862972 PMCID: PMC5586478 DOI: 10.1161/jaha.117.006835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
88
|
Uretsky S, Argulian E, Supariwala A, Agarwal SK, El-Hayek G, Chavez P, Awan H, Jagarlamudi A, Puppala SP, Cohen R, Rozanski A. Comparative effectiveness of coronary CT angiography vs stress cardiac imaging in patients following hospital admission for chest pain work-up: The Prospective First Evaluation in Chest Pain (PERFECT) Trial. J Nucl Cardiol 2017; 24:1267-1278. [PMID: 27048306 DOI: 10.1007/s12350-015-0354-6] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 10/20/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Because the frequency of cardiac event rates is low among chest pain patients following either performance of coronary CT angiography (CCTA) or stress testing, there is a need to better assess how these tests influence the central management decisions that follow from cardiac testing. The present study was performed to assess the relative impact of CCTA vs stress testing on medical therapies and downstream resource utilization among patients admitted for the work-up of chest pain. METHODS The admitted patients were randomized in a 1:1 ratio to either cardiac imaging stress test or CCTA. Primary outcomes were time to discharge, change in medication usage, and frequency of downstream testing, cardiac interventions, and cardiovascular re-hospitalizations. We randomized 411 patients, 205 to stress testing, and 206 to CCTA. RESULTS There were no differences in time to discharge or initiation of new cardiac medications at discharge. At 1 year follow-up, there was no difference in the number of patients who underwent cardiovascular downstream tests in the CCTA vs stress test patients (21% vs 15%, P = .1) or cardiovascular hospitalizations (14% vs 16%, P = .5). However, there was a higher frequency of invasive angiography in the CCTA group (11% vs 2%, P = .001) and percutaneous coronary interventions (6% vs 0%, P < .001). CONCLUSIONS Randomization of hospitalized patients admitted for chest pain work-up to either CCTA or to stress testing resulted in similar discharge times, change in medical therapies at discharge, frequency of downstream noninvasive testing, and repeat hospitalizations. However, a higher frequency of invasive coronary angiography and revascularization procedures were performed in the CCTA arm. (ClinicalTrials.gov number, NCT01604655.).
Collapse
Affiliation(s)
- Seth Uretsky
- Department of Cardiovascular Medicine, Morristown Medical Center, Gagnon Cardiovascular Institute, 100 Madison Ave, Morristown, NJ, 07960, USA.
| | - Edgar Argulian
- Division of Cardiology, Department of Medicine, Mount Sinai St. Luke's Hospital, New York, NY, USA
| | - Azhar Supariwala
- Northshore LIJ Southside Hospital, Hofstra School of Medicine, NSLIJHS, Bayshore, NY, USA
| | - Shiv K Agarwal
- Department of Cardiovascular Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Georges El-Hayek
- Division of Cardiology, Department of Medicine, Mount Sinai St. Luke's Hospital, New York, NY, USA
| | - Patricia Chavez
- Division of Cardiology, Department of Medicine, Mount Sinai St. Luke's Hospital, New York, NY, USA
| | - Hira Awan
- Division of Cardiology, Department of Medicine, Mount Sinai St. Luke's Hospital, New York, NY, USA
| | - Ashadevi Jagarlamudi
- Division of Cardiology, Department of Medicine, Mount Sinai St. Luke's Hospital, New York, NY, USA
| | - Siva P Puppala
- Division of Cardiology, Department of Medicine, Mount Sinai St. Luke's Hospital, New York, NY, USA
| | - Randy Cohen
- Division of Cardiology, Department of Medicine, Mount Sinai St. Luke's Hospital, New York, NY, USA
| | - Alan Rozanski
- Division of Cardiology, Department of Medicine, Mount Sinai St. Luke's Hospital, New York, NY, USA
| |
Collapse
|
89
|
Durand E, Bauer F, Mansencal N, Azarine A, Diebold B, Hagege A, Perdrix L, Gilard M, Jobic Y, Eltchaninoff H, Bensalah M, Dubourg B, Caudron J, Niarra R, Chatellier G, Dacher JN, Mousseaux E. Head-to-head comparison of the diagnostic performance of coronary computed tomography angiography and dobutamine-stress echocardiography in the evaluation of acute chest pain with normal ECG findings and negative troponin tests: A prospective multicenter study. Int J Cardiol 2017; 241:463-469. [DOI: 10.1016/j.ijcard.2017.02.129] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 12/10/2016] [Accepted: 02/24/2017] [Indexed: 11/15/2022]
|
90
|
Bittencourt MS, Blankstein R. Coronary computed tomography angiography: How should we act on what we find? J Nucl Cardiol 2017; 24:1279-1281. [PMID: 27072002 DOI: 10.1007/s12350-016-0494-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Revised: 03/29/2016] [Indexed: 11/25/2022]
Affiliation(s)
- Márcio Sommer Bittencourt
- Center for Clinical and Epidemiological Research, University Hospital and State of São Paulo Cancer Institute (ICESP), University of São Paulo, São Paulo, Brazil
- Preventive Medicine Center, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Ron Blankstein
- Non-Invasive Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital and Harvard Medical School, 75 Francis St, Boston, MA, 02115, USA.
| |
Collapse
|
91
|
Abstract
Coronary computed tomographic angiography has become a reliable diagnostic tool in the evaluation of patients with chest pain. Studies have shown this modality to be accurate and safe when compared with conventional methods of assessing patients with chest pain. We review the recent developments with coronary computed tomographic angiography and devote particular attention toward its application to triage patients in the emergency department.
Collapse
Affiliation(s)
- Nikhil Goyal
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA, USA
| | - Arthur Stillman
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA, USA
| |
Collapse
|
92
|
Dweck MR, Williams MC, Moss AJ, Newby DE, Fayad ZA. Computed Tomography and Cardiac Magnetic Resonance in Ischemic Heart Disease. J Am Coll Cardiol 2017; 68:2201-2216. [PMID: 27855810 PMCID: PMC5181647 DOI: 10.1016/j.jacc.2016.08.047] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 08/01/2016] [Accepted: 08/05/2016] [Indexed: 01/30/2023]
Abstract
Ischemic heart disease is a complex disease process caused by the development of coronary atherosclerosis, with downstream effects on the left ventricular myocardium. It is characterized by a long preclinical phase, abrupt development of myocardial infarction, and more chronic disease states such as stable angina and ischemic cardiomyopathy. Recent advances in computed tomography (CT) and cardiac magnetic resonance (CMR) now allow detailed imaging of each of these different phases of the disease, potentially allowing ischemic heart disease to be tracked during a patient’s lifetime. In particular, CT has emerged as the noninvasive modality of choice for imaging the coronary arteries, whereas CMR offers detailed assessments of myocardial perfusion, viability, and function. The clinical utility of these techniques is increasingly being supported by robust randomized controlled trial data, although the widespread adoption of cardiac CT and CMR will require further evidence of clinical efficacy and cost effectiveness.
Collapse
Affiliation(s)
- Marc R Dweck
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Michelle C Williams
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Alastair J Moss
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - David E Newby
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Zahi A Fayad
- Translational and Molecular Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, New York; Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York.
| |
Collapse
|
93
|
Stănescu A, Himcinschi E, Morariu M, Rat N, Bordi L, Rațiu M, Benedek A, Benedek I, Benedek T. Cardiac Computed Tomography Assessment in Acute Coronary Syndromes — Do We Have Time for It in Emergency Settings? JOURNAL OF INTERDISCIPLINARY MEDICINE 2017. [DOI: 10.1515/jim-2017-0051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
The diagnosis and treatment of acute coronary syndrome remain a challenge for clinicians in many clinical settings, especially in patients with previous low-to-intermediate risk. Due to its high specificity and sensitivity for detecting significant coronary artery stenoses, cardiac computed tomography angiography (CCTA) tends to be used more frequently in the emergency room (ER) in the last years. This technique has been associated with a higher rate of safe discharge in patients with chest pain, less time spent in the ER, and decreased costs related to further investigations. In cases positive for coronary artery stenosis, CCTA can accurately evaluate the indication for percutaneous coronary angioplasty and can offer relevant information related to the characteristics of the coronary plaques, being able to detect vulnerable coronary plaques. The aim of this manuscript is to highlight the possibility of using CCTA in the ER in the assessment of patients with chest pain and to show the benefits of the procedure regarding safety, costs, accuracy, and time.
Collapse
Affiliation(s)
- Alexandra Stănescu
- University of Medicine and Pharmacy , Tîrgu Mureș , Romania
- Center of Advanced Research in Multimodality Cardiac Imaging , Cardio Med Medical Center , Tîrgu Mureș , Romania
| | - Elisabeta Himcinschi
- Center of Advanced Research in Multimodality Cardiac Imaging , Cardio Med Medical Center , Tîrgu Mureș , Romania
| | - Mirabela Morariu
- University of Medicine and Pharmacy , Tîrgu Mureș , Romania
- Center of Advanced Research in Multimodality Cardiac Imaging , Cardio Med Medical Center , Tîrgu Mureș , Romania
| | - Nora Rat
- University of Medicine and Pharmacy , Tîrgu Mureș , Romania
- Center of Advanced Research in Multimodality Cardiac Imaging , Cardio Med Medical Center , Tîrgu Mureș , Romania
| | - Lehel Bordi
- Center of Advanced Research in Multimodality Cardiac Imaging , Cardio Med Medical Center , Tîrgu Mureș , Romania
| | - Mihaela Rațiu
- University of Medicine and Pharmacy , Tîrgu Mureș , Romania
- Center of Advanced Research in Multimodality Cardiac Imaging , Cardio Med Medical Center , Tîrgu Mureș , Romania
| | | | - Imre Benedek
- University of Medicine and Pharmacy , Tîrgu Mureș , Romania
- Center of Advanced Research in Multimodality Cardiac Imaging , Cardio Med Medical Center , Tîrgu Mureș , Romania
| | - Theodora Benedek
- University of Medicine and Pharmacy , Tîrgu Mureș , Romania
- Center of Advanced Research in Multimodality Cardiac Imaging , Cardio Med Medical Center , Tîrgu Mureș , Romania
| |
Collapse
|
94
|
Affiliation(s)
- Koen Nieman
- From the Department of Cardiovascular Medicine and Department of Radiology, Stanford School of Medicine, CA.
| |
Collapse
|
95
|
Korley FK, Gatsonis C, Snyder BS, George RT, Abd T, Zimmerman SL, Litt HI, Hollander JE. Clinical risk factors alone are inadequate for predicting significant coronary artery disease. J Cardiovasc Comput Tomogr 2017; 11:309-316. [PMID: 28487137 DOI: 10.1016/j.jcct.2017.04.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 03/10/2017] [Accepted: 04/25/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE We sought to derive and validate a model for identifying suspected ACS patients harboring undiagnosed significant coronary artery disease (CAD). METHODS This was a secondary analysis of data from a randomized control trial (RCT). Patients randomized to the CTA arm of an RCT examining a CTA-based strategy for ruling-out acute coronary syndrome (ACS) constitute the derivation cohort, which was randomly divided into a training dataset (2/3, used for model derivation) and a test dataset (1/3, used for internal validation (IV)). ED patients from a different center receiving CTA to evaluate for suspected ACS constitute the external validation (EV) cohort. Primary outcome was CTA-assessed significant CAD (stenosis of ≥50% in a major coronary artery). RESULTS In the derivation cohort, 11.2% (76/679) of subjects had CTA-assessed significant CAD, and in the EV cohort, 8.2% of subjects (87/1056) had CTA-assessed significant CAD. Age was the strongest predictor of significant CAD among the clinical risk factors examined. Predictor variables included in the derived logistic regression model were: age, sex, tobacco use, diabetes, and race. This model exhibited an area under the receiver operating characteristic curve (ROC AUC) of 0.72 (95% CI: 0.61-0.83) based on IV, and 0.76 (95% CI: 0.70, 0.82) based on EV. The derived random forest model based on clinical risk factors yielded improved but not sufficient discrimination of significant CAD (ROC AUC = 0.76 [95% CI: 0.67-0.85] based on IV). Coronary artery calcium score was a more accurate predictor of significant CAD than any combination of clinical risk factors (ROC AUC = 0.85 [95% CI: 0.76-0.94] based on IV; ROC AUC = 0.92 [95% CI: 0.88-0.95] based on EV). CONCLUSIONS Clinical risk factors, either individually or in combination, are insufficient for accurately identifying suspected ACS patients harboring undiagnosed significant coronary artery disease.
Collapse
Affiliation(s)
- Frederick K Korley
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI, United States.
| | - Constantine Gatsonis
- Center for Statistical Sciences and Department of Biostatistics, Brown University School of Public Health, Providence, RI, United States.
| | - Bradley S Snyder
- Center for Statistical Sciences, Brown University School of Public Health, Providence, RI, United States.
| | - Richard T George
- Adjunct Faculty, Division of Cardiology, Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| | - Thura Abd
- Division of Cardiology, Department of Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| | - Stefan L Zimmerman
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| | - Harold I Litt
- Department of Radiology and Division of Cardiovascular Medicine, Department of Internal Medicine, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, United States.
| | - Judd E Hollander
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA, United States.
| |
Collapse
|
96
|
Abstract
Coronary artery disease (CAD) continues to be a leading cause of morbidity and mortality worldwide. Although invasive coronary angiography has previously been the gold standard in establishing the diagnosis of CAD, there is a growing shift to more appropriately use the cardiac catheterization laboratory to perform interventional procedures once a diagnosis of CAD has been established by noninvasive imaging modalities rather than using it primarily as a diagnostic facility to confirm or refute CAD. With ongoing technological advancements, noninvasive imaging plays a pre-eminent role in not only diagnosing CAD but also informing the choice of appropriate therapies, establishing prognosis, all while containing costs and providing value-based care. Multiple imaging modalities are available to evaluate patients suspected of having coronary ischemia, such as stress electrocardiography, stress echocardiography, single-photon emission computed tomography myocardial perfusion imaging, positron emission tomography, coronary computed tomography (CT) angiography, and magnetic resonance imaging. These imaging modalities can variably provide functional and anatomical delineation of coronary stenoses and help guide appropriate therapy. This review will discuss their advantages and limitations and their usage in the diagnostic pathway for patients with CAD. We also discuss newer technologies such as CT fractional flow reserve, CT angiography with perfusion, whole-heart coronary magnetic resonance angiography with perfusion, which can provide both anatomical as well as functional information in the same test, thus obviating the need for multiple diagnostic tests to obtain a comprehensive assessment of both, plaque burden and downstream ischemia. Recognizing that clinicians have a multitude of tests to choose from, we provide an underpinning of the principles of ischemia detection by these various modalities, focusing on anatomy vs physiology, the database justifying their use, their prognostic capabilities and lastly, their appropriate and judicious use in this era of patient-centered, cost-effective imaging.
Collapse
|
97
|
Karthikeyan G, Guzic Salobir B, Jug B, Devasenapathy N, Alexanderson E, Vitola J, Kraft O, Ozkan E, Sharma S, Purohit G, Dolenc Novak M, Meave A, Trevethan S, Cerci R, Zier S, Gotthardtová L, Jonszta T, Altin T, Soydal C, Patel C, Gulati G, Paez D, Dondi M, Kashyap R. Functional compared to anatomical imaging in the initial evaluation of patients with suspected coronary artery disease: An international, multi-center, randomized controlled trial (IAEA-SPECT/CTA study). J Nucl Cardiol 2017; 24:507-517. [PMID: 27796852 PMCID: PMC5413523 DOI: 10.1007/s12350-016-0664-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Revised: 08/14/2016] [Accepted: 08/14/2016] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To test the hypothesis that, in the initial evaluation of patients with suspected coronary artery disease (CAD), stress myocardial perfusion imaging (MPI) would result in less downstream testing than coronary computed tomographic angiography (CCTA). METHODS In this international, randomized trial, mildly symptomatic patients with an intermediate likelihood of having CAD, and asymptomatic patients at intermediate risk of cardiac events, underwent either initial stress-rest MPI or CCTA. The primary outcome was downstream noninvasive or invasive testing at 6 months. Secondary outcomes included cumulative effective radiation dose (ERD) and costs at 12 months. RESULTS We recruited 303 patients (151 MPI and 152 CTA) from 6 centers in 6 countries. The initial MPI was abnormal in 29% (41/143) and CCTA in 56% (79/141) of patients. Fewer patients undergoing initial stress-rest MPI had further downstream testing at 6 months (adjusted OR 0.51, 95% CI 0.28-0.91, P = 0.023). There was a small increase in the median cumulative ERD with MPI (9.6 vs. 8.8 mSv, P = 0.04), but no difference in costs between the two strategies at 12 months. CONCLUSION In the management of patients with suspected CAD, a strategy of initial stress MPI is substantially less likely to require further downstream testing than initial testing with CCTA. TRIAL REGISTRATION clinicaltrials.gov identification number NCT01368770.
Collapse
Affiliation(s)
- Ganesan Karthikeyan
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, 110029, India.
| | - Barbara Guzic Salobir
- Department of Nuclear Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Borut Jug
- Department of Vascular Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | | | - Erick Alexanderson
- Department of Nuclear Medicine, Ignacio Chávez National Institute of Cardiology, Mexico City, Mexico
| | - Joao Vitola
- Quanta Diagnóstico & Terapia, Curitiba, Brazil
| | - Otakar Kraft
- Department of Nuclear Medicine, Faculty Hospital Ostrava, Ostrava, Czech Republic
| | - Elgin Ozkan
- Department of Nuclear Medicine, Ankara University Medical Faculty, Ankara, Turkey
| | - Saket Sharma
- Indian Institute of Public Health-Delhi, Gurgaon, India
| | - Gaurav Purohit
- Department of Cardiology, All India Institute of Medical Sciences, New Delhi, 110029, India
| | - Maja Dolenc Novak
- Department of Nuclear Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Aloha Meave
- Department of Radiology, Ignacio Chávez National Institute of Cardiology, Mexico City, Mexico
| | - Sergio Trevethan
- Department of Nuclear Medicine, Ignacio Chávez National Institute of Cardiology, Mexico City, Mexico
| | | | - Sandra Zier
- Quanta Diagnóstico & Terapia, Curitiba, Brazil
| | - Lucia Gotthardtová
- Department of Cardiology, Faculty Hospital Ostrava, Ostrava, Czech Republic
| | - Tomáš Jonszta
- Department of Radiology, Faculty Hospital Ostrava, Ostrava, Czech Republic
| | - Timucin Altin
- Department of Cardiology, Ankara University Medical Faculty, Ankara, Turkey
| | - Cigdem Soydal
- Department of Nuclear Medicine, Ankara University Medical Faculty, Ankara, Turkey
| | - Chetan Patel
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Gurpreet Gulati
- Department of Cardiac Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Diana Paez
- Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Austria
| | - Maurizio Dondi
- Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Austria
| | - Ravi Kashyap
- Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Austria
| |
Collapse
|
98
|
Trials of Imaging Use in the Emergency Department for Acute Chest Pain. JACC Cardiovasc Imaging 2017; 10:338-349. [DOI: 10.1016/j.jcmg.2016.10.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 10/27/2016] [Accepted: 10/27/2016] [Indexed: 02/06/2023]
|
99
|
Trattner S, Chelliah A, Prinsen P, Ruzal-Shapiro CB, Xu Y, Jambawalikar S, Amurao M, Einstein AJ. Estimating Effective Dose of Radiation From Pediatric Cardiac CT Angiography Using a 64-MDCT Scanner: New Conversion Factors Relating Dose-Length Product to Effective Dose. AJR Am J Roentgenol 2017; 208:585-594. [PMID: 28095022 PMCID: PMC6195128 DOI: 10.2214/ajr.15.15908] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVE The purpose of this study is to determine the conversion factors that enable accurate estimation of the effective dose (ED) used for cardiac 64-MDCT angiography performed for children. MATERIALS AND METHODS Anthropomorphic phantoms representative of 1- and 10-year-old children, with 50 metal oxide semiconductor field-effect transistor dosimeters placed in organs, underwent scanning performed using a 64-MDCT scanner with different routine clinical cardiac scan modes and x-ray tube potentials. Organ doses were used to calculate the ED on the basis of weighting factors published in 1991 in International Commission on Radiological Protection (ICRP) publication 60 and in 2007 in ICRP publication 103. The EDs and the scanner-reported dose-length products were used to determine conversion factors for each scan mode. The effect of infant heart rate on the ED and the conversion factors was also assessed. RESULTS The mean conversion factors calculated using the current definition of ED that appeared in ICRP publication 103 were as follows: 0.099 mSv · mGy-1 · cm-1, for the 1-year-old phantom, and 0.049 mSv · mGy-1 · cm-1, for the 10-year-old phantom. These conversion factors were a mean of 37% higher than the corresponding conversion factors calculated using the older definition of ED that appeared in ICRP publication 60. Varying the heart rate did not influence the ED or the conversion factors. CONCLUSION Conversion factors determined using the definition of ED in ICRP publication 103 and cardiac, rather than chest, scan coverage suggest that the radiation doses that children receive from cardiac CT performed using a contemporary 64-MDCT scanner are higher than the radiation doses previously reported when older chest conversion factors were used. Additional up-to-date pediatric cardiac CT conversion factors are required for use with other contemporary CT scanners and patients of different age ranges.
Collapse
Affiliation(s)
- Sigal Trattner
- 1 Department of Medicine, Cardiology Division, Columbia University Medical Center, New York, NY
| | - Anjali Chelliah
- 2 Department of Pediatrics, Pediatric Cardiology Division, New York-Presbyterian Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, NY
| | - Peter Prinsen
- 3 Philips Healthcare Research, Eindhoven, The Netherlands
| | | | - Yanping Xu
- 5 Radiological Research Accelerator Facility, Center for Radiological Research, Columbia University, Irvington, NY
| | | | - Maxwell Amurao
- 6 Radiation Safety Office, Columbia University Medical Center, New York, NY
| | - Andrew J Einstein
- 7 Department of Medicine, Cardiology Division and Department of Radiology, Columbia University Medical Center and New York-Presbyterian Hospital, 622 W 168th St, PH 10-203A, New York, NY 10032
| |
Collapse
|
100
|
Gray AJ, Roobottom C, Smith JE, Goodacre S, Oatey K, O’Brien R, Storey RF, Na L, Lewis SC, Thokala P, Newby DE. The RAPID-CTCA trial (Rapid Assessment of Potential Ischaemic Heart Disease with CTCA) - a multicentre parallel-group randomised trial to compare early computerised tomography coronary angiography versus standard care in patients presenting with suspected or confirmed acute coronary syndrome: study protocol for a randomised controlled trial. Trials 2016; 17:579. [PMID: 27923390 PMCID: PMC5142154 DOI: 10.1186/s13063-016-1717-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 11/19/2016] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Emergency department attendances with chest pain requiring assessment for acute coronary syndrome (ACS) are a major global health issue. Standard assessment includes history, examination, electrocardiogram (ECG) and serial troponin testing. Computerised tomography coronary angiography (CTCA) enables additional anatomical assessment of patients for coronary artery disease (CAD) but has only been studied in very low-risk patients. This trial aims to investigate the effect of early CTCA upon interventions, event rates and health care costs in patients with suspected/confirmed ACS who are at intermediate risk. METHODS/DESIGN Participants will be recruited in about 35 tertiary and district general hospitals in the UK. Patients ≥18 years old with symptoms with suspected/confirmed ACS with at least one of the following will be included: (1) ECG abnormalities, e.g. ST-segment depression >0.5 mm; (2) history of ischaemic heart disease; (3) troponin elevation above the 99th centile of the normal reference range or increase in high-sensitivity troponin meeting European Society of Cardiology criteria for 'rule-in' of myocardial infarction (MI). The early use of ≥64-slice CTCA as part of routine assessment will be compared to standard care. The primary endpoint will be 1-year all-cause death or recurrent type 1 or type 4b MI at 1 year, measured as the time to such event. A number of secondary clinical, process and safety endpoints will be collected and analysed. Cost effectiveness will be estimated in terms of the lifetime incremental cost per quality-adjusted life year gained. We plan to recruit 2424 (2500 with ~3% drop-out) evaluable patients (1212 per arm) to have 90% power to detect a 20% versus 15% difference in 1-year death or recurrent type 1 MI or type 4b MI, two-sided p < 0.05. Analysis will be on an intention-to-treat basis. The relationship between intervention and the primary outcome will be analysed using Cox proportional hazard regression adjusted for study site (used to stratify the randomisation), age, baseline Global Registry of Acute Coronary Events score, previous CAD and baseline troponin level. The results will be expressed as a hazard ratio with the corresponding 95% confidence intervals and p value. DISCUSSION The Rapid Assessment of Potential Ischaemic Heart Disease with CTCA (RAPID-CTCA) trial will recruit 2500 participants across about 35 hospital sites. It will be the first study to investigate the role of CTCA in the early assessment of patients with suspected or confirmed ACS who are at intermediate risk and including patients who have raised troponin measurements during initial assessment. TRIAL REGISTRATION ISRCTN19102565 . Registered on 3 October 2014. ClinicalTrials.gov: NCT02284191.
Collapse
Affiliation(s)
- Alasdair J. Gray
- Department of Emergency Medicine, Emergency Medicine Research Group, Royal Infirmary of Edinburgh, Edinburgh, UK
- University of Edinburgh, British Heart Foundation, Centre for Cardiovascular Science, Edinburgh, UK
| | - Carl Roobottom
- Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
- Derriford Hospital, Plymouth Hospitals NHS Trust, Plymouth, UK
| | - Jason E. Smith
- Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
- Derriford Hospital, Plymouth Hospitals NHS Trust, Plymouth, UK
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Birmingham, UK
| | - Steve Goodacre
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Katherine Oatey
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Rachel O’Brien
- Department of Emergency Medicine, Emergency Medicine Research Group, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Robert F. Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Lumine Na
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Steff C. Lewis
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Praveen Thokala
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - David E. Newby
- University of Edinburgh, British Heart Foundation, Centre for Cardiovascular Science, Edinburgh, UK
| |
Collapse
|