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Kashiwagi M, Tanaka A, Kitabata H, Ozaki Y, Komukai K, Tanimoto T, Ino Y, Kubo T, Hirata K, Imanishi T, Akasaka T. Comparison of diagnostic accuracy between multidetector computed tomography and virtual histology intravascular ultrasound for detecting optical coherence tomography-derived fibroatheroma. Cardiovasc Interv Ther 2013; 29:102-8. [PMID: 24150708 DOI: 10.1007/s12928-013-0219-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Accepted: 10/09/2013] [Indexed: 11/25/2022]
Abstract
Histopathological studies have reported that optical coherence tomography (OCT) can accurately detect fibroatheroma that is involved in not only culprit lesion of acute coronary syndrome but also no-reflow phenomenon after percutaneous coronary intervention. Studies have demonstrated superiority of OCT in plaque characterization and interruption of arterial wall component. At current, multidetector computed tomography (MDCT) and virtual histology intravascular ultrasound (VH-IVUS) are considered as alternative imaging devices for coronary plaque characterization. This study aimed to compare the diagnostic accuracy for detecting fibroatheroma between MDCT and VH-IVUS using OCT as the reference standard. Forty-three lesions from 27 patients assessed by MDCT, VH-IVUS, and OCT were included in this study. Fibroatheroma was defined by OCT as a signal-poor region with a fast signal drop-off and little or no signal backscattering within the lesion. From 43 lesions, OCT revealed 21 fibroatheromas. Ring-like sign assessed by MDCT and positive remodeling assessed by IVUS were more frequently observed in OCT-fibroatheroma than non-OCT-fibroatheroma. The remodeling index of OCT-fibroatheroma assessed by MDCT and IVUS were higher than those of non-OCT-fibroatheroma. The sensitivity, specificity, positive predict values, negative predict values and accuracy of ring-like sign by MDCT and VH-IVUS for detecting OCT-fibroatheroma were 43, 95, 90, 64, 70 % and 71, 45, 56, 63, 58 %, respectively. Our results suggest that both accuracies of MDCT and VH-IVUS to detect OCT-fibroatheroma are insufficient. We need to apply appropriate device for searching vulnerable plaque.
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Affiliation(s)
- Manabu Kashiwagi
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan,
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dos Prazeres CEE, Cury RC, Carneiro ACDC, Rochitte CE. Coronary computed tomography angiography in the assessment of acute chest pain in the emergency room. Arq Bras Cardiol 2013; 101:562-9. [PMID: 24145392 PMCID: PMC4106815 DOI: 10.5935/abc.20130208] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Accepted: 07/10/2013] [Indexed: 11/26/2022] Open
Abstract
The coronary computed tomography angiography has recently emerged as an accurate
diagnostic tool in the evaluation of coronary artery disease, providing
diagnostic and prognostic data that correlate directly with the data provided by
invasive coronary angiography. The association of recent technological
developments has allowed improved temporal resolution and better spatial
coverage of the cardiac volume with significant reduction in radiation dose, and
with the crucial need for more effective protocols of risk stratification of
patients with chest pain in the emergency room, recent evaluation of the
computed tomography coronary angiography has been performed in the setting of
acute chest pain, as about two thirds of invasive coronary angiographies show no
significantly obstructive coronary artery disease. In daily practice, without
the use of more efficient technologies, such as coronary angiography by computed
tomography, safe and efficient stratification of patients with acute chest pain
remains a challenge to the medical team in the emergency room. Recently, several studies, including three randomized trials, showed favorable
results with the use of this technology in the emergency department for patients
with low to intermediate likelihood of coronary artery disease. In this review,
we show data resulting from coronary angiography by computed tomography in risk
stratification of patients with chest pain in the emergency room, its diagnostic
value, prognosis and cost-effectiveness and a critical analysis of recently
published multicenter studies.
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Affiliation(s)
| | | | | | - Carlos Eduardo Rochitte
- Hospital do Coração - HCor, Associação do Sanatório Sírio, São
Paulo, SP - Brazil
- Instituto do Coração - InCor - HCFMUSP, São Paulo, SP -
Brazil
- Mailing Address: Prof. Dr. Carlos Eduardo Rochitte, Rua
Desembargardor Eliseu Guilherme, 123, 3o. Subsolo - Ressonância e Tomografia
Cardiovascular, Paraíso, São Paulo - SP - Brazil, Postal Code 04004-030. E-mail:
,
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Bertens LCM, Broekhuizen BDL, Naaktgeboren CA, Rutten FH, Hoes AW, van Mourik Y, Moons KGM, Reitsma JB. Use of expert panels to define the reference standard in diagnostic research: a systematic review of published methods and reporting. PLoS Med 2013; 10:e1001531. [PMID: 24143138 PMCID: PMC3797139 DOI: 10.1371/journal.pmed.1001531] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2013] [Accepted: 09/03/2013] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND In diagnostic studies, a single and error-free test that can be used as the reference (gold) standard often does not exist. One solution is the use of panel diagnosis, i.e., a group of experts who assess the results from multiple tests to reach a final diagnosis in each patient. Although panel diagnosis, also known as consensus or expert diagnosis, is frequently used as the reference standard, guidance on preferred methodology is lacking. The aim of this study is to provide an overview of methods used in panel diagnoses and to provide initial guidance on the use and reporting of panel diagnosis as reference standard. METHODS AND FINDINGS PubMed was systematically searched for diagnostic studies applying a panel diagnosis as reference standard published up to May 31, 2012. We included diagnostic studies in which the final diagnosis was made by two or more persons based on results from multiple tests. General study characteristics and details of panel methodology were extracted. Eighty-one studies were included, of which most reported on psychiatry (37%) and cardiovascular (21%) diseases. Data extraction was hampered by incomplete reporting; one or more pieces of critical information about panel reference standard methodology was missing in 83% of studies. In most studies (75%), the panel consisted of three or fewer members. Panel members were blinded to the results of the index test results in 31% of studies. Reproducibility of the decision process was assessed in 17 (21%) studies. Reported details on panel constitution, information for diagnosis and methods of decision making varied considerably between studies. CONCLUSIONS Methods of panel diagnosis varied substantially across studies and many aspects of the procedure were either unclear or not reported. On the basis of our review, we identified areas for improvement and developed a checklist and flow chart for initial guidance for researchers conducting and reporting of studies involving panel diagnosis. Please see later in the article for the Editors' Summary.
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Affiliation(s)
- Loes C. M. Bertens
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, The Netherlands
- * E-mail:
| | - Berna D. L. Broekhuizen
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, The Netherlands
| | | | - Frans H. Rutten
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, The Netherlands
| | - Arno W. Hoes
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, The Netherlands
| | - Yvonne van Mourik
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, The Netherlands
| | - Karel G. M. Moons
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, The Netherlands
| | - Johannes B. Reitsma
- Julius Centre for Health Sciences and Primary Care, University Medical Centre Utrecht, The Netherlands
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Stenosis quantification of coronary arteries in coronary vessel phantoms with second-generation dual-source CT: influence of measurement parameters and limitations. AJR Am J Roentgenol 2013; 201:W227-34. [PMID: 23883237 DOI: 10.2214/ajr.12.9453] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study was to use second-generation dual-source CT to assess the influence of size, degree of stenosis, luminal contrast attenuation, and plaque geometry on stenosis quantification in a coronary artery phantom. MATERIALS AND METHODS Six vessel phantoms with three outer diameters (2, 3, and 4 mm), each containing three radiolucent plaques (72.2 HU) that simulated eccentric and concentric 43.8%, 75%, and 93.8% stenoses were made with a 3D printer system. These phantoms were filled with an iodine-saline solution mixture at luminal attenuations of 150, 200, 250, 300, and 350 HU and were attached to a cardiac motion simulator. Dual-source CT was performed with a standardized ECG-gated protocol (120 kV, 360 mAs per rotation) at a simulated heart rate of 70 beats/min. Two independent readers quantified the degree of stenosis using area-based measurements. RESULTS All measurements were highly reproducible (intraclass correlation, ≥ 0.791; p < 0.001). The mean measured degree of stenosis for a phantom with a 3-mm outer diameter at 250-HU luminal attenuation was 49.0% ± 10.0% for 43.8% stenosis, 71.7% ± 9.6% for 75.0% stenosis, and 85.4% ± 5.9% for 93.8% stenosis. With decreasing phantom size, measurement error increased for all degrees of stenosis. The absolute error increased for measurements at a low luminal attenuation of 150 HU (p < 0.001) and for low-grade stenoses compared with medium-and high-grade stenoses (p < 0.001). CONCLUSION The results are an overview of factors that influence stenosis quantification in simulated coronary arteries. Dual-source CT is highly reproducible and accurate for quantification of low-density stenosis in vessels with a diameter of 3 mm and attenuation of at least 200 HU for different degrees of stenosis and plaque geometry.
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Meyer M, Schoepf UJ, Fink C, Goldenberg R, Apfaltrer P, Gruettner J, Vajcs D, Schoenberg SO, Henzler T. Diagnostic performance evaluation of a computer-aided simple triage system for coronary CT angiography in patients with intermediate risk for acute coronary syndrome. Acad Radiol 2013; 20:980-6. [PMID: 23735619 DOI: 10.1016/j.acra.2013.02.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Revised: 02/25/2013] [Accepted: 02/26/2013] [Indexed: 10/26/2022]
Abstract
RATIONALE AND OBJECTIVES Given the significance of coronary artery disease as the most important socioeconomic health care problem in the Western World, the application of computer-aided simple triage (CAST) systems to this disease would be desirable. MATERIALS AND METHODS In total, 93 patients with acute chest pain and an intermediate risk score for acute coronary syndrome underwent coronary computed tomography angiography (cCTA). Among those, 74 were of adequate image quality for automated analysis by a commercially available CAST system (COR Analyzer, RCADIA, Haifa, Israel). CAST findings were compared to human expert interpretation for the detection of significant stenosis (≥50%) in the left main, left anterior descending, circumflex, right coronary artery, or arterial branches. Further, one inexperienced observer evaluated all studies for significant stenoses alone and after 1 month guided by a CAST system as an initial read. RESULTS Human expert interpretation identified 37/74 patients with stenosis ≥50%, whereas the CAST detected 45 patients. The CAST system demonstrated a sensitivity of 100%/79% and a specificity of 78%/89% on a per-patient/per-vessel level, respectively. With CAST, the inexperienced readers' per-vessel sensitivity and positive predictive values significantly improved (P = .011, P = .009) from 69% and 41% to 91% and 74%, respectively. CONCLUSIONS The investigated CAST system for automatic stenosis detection can accurately identify patients with coronary artery stenosis ≥50% and may be of use as initial interpretation and triage of cCTA studies as well as a second reader for inexperienced readers, in absence of expert readers.
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Engel LC, Lee AM, Seifarth H, Sidhu MS, Brady TJ, Hoffmann U, Ghoshhajra BB. Weekly dose reports: the effects of a continuous quality improvement initiative on coronary computed tomography angiography radiation doses at a tertiary medical center. Acad Radiol 2013; 20:1015-23. [PMID: 23830607 DOI: 10.1016/j.acra.2013.04.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Revised: 04/14/2013] [Accepted: 04/30/2013] [Indexed: 01/04/2023]
Abstract
RATIONALE AND OBJECTIVES Numerous protocols have been developed to reduce cardiac computed tomography angiography (cCTA) radiation dose while maintaining image quality. However, cCTA practice is highly dependent on physician and technologist experience and education. In this study, we sought to evaluate the incremental value of real-time feedback via weekly dose reports on a busy cCTA service. MATERIALS AND METHODS This time series analysis consisted of 450 consecutive patients whom underwent physician-supervised cCTA for clinically indicated native coronary evaluation between April 2011 and January 2013, with 150 patients before the initiation of weekly dose report (preintervention period: April-September 2011) and 150 patients after the initiation (postintervention period: September 2011-February 2012). To assess whether overall dose reductions were maintained over time, results were compared to a late control group consisting of 150 consecutive cCTA exams, which were performed after the study (September 2012-January 2013). Patient characteristics and effective radiation were recorded and compared. RESULTS Total radiation dose was significantly lower in the postintervention period (3.4 mSv [1.7-5.7] and in the late control group (3.3 mSv [2.0-5.3] versus the preintervention period (4.1 mSv [2.1-6.6] (P = .005). The proportion of high-dose outliers was also decreased in the postintervention period and late control period (exams <10 mSv were 88.0% preintervention vs. 97.3% postintervention vs. 95.3% late control; exams <15 mSv were 98.0% preintervention vs. 100.0% postintervention vs. 98.7% late control; exams <20.0 mSv were 98.7% preintervention vs. 100.0% postintervention vs. 100.0% late control). CONCLUSION Weekly dose report feedback of site radiation doses to patients undergoing physician-supervised cCTA resulted in significant overall dose reduction and reduction of high-dose outliers. Overall dose reductions were maintained beyond the initial study period.
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Affiliation(s)
- Leif-Christopher Engel
- Cardiac MR PET CT Program, Department of Radiology and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge St., Suite 400, Boston, MA 02114, USA
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Atherosclerotic plaque burden in cocaine users with acute chest pain: Analysis by coronary computed tomography angiography. Atherosclerosis 2013; 229:443-8. [DOI: 10.1016/j.atherosclerosis.2013.05.032] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Revised: 04/19/2013] [Accepted: 05/30/2013] [Indexed: 11/22/2022]
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Cardiac computed tomography angiography with automatic tube potential selection: effects on radiation dose and image quality. J Thorac Imaging 2013; 28:40-8. [PMID: 22847638 DOI: 10.1097/rti.0b013e3182631e8a] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Automatic exposure control (AEC) algorithms are widely available in coronary computed tomography angiography (CTA) and have been shown to reduce radiation doses by adjusting tube current to patient size. However, the effects of anthropometry-based automatic potential selection (APS) on image quality and radiation dose are unknown. We sought to investigate the effect of an APS algorithm on coronary CTA radiation dose and image quality. MATERIALS AND METHODS For this retrospective case-control study we selected 38 patients who had undergone coronary CTA for coronary artery assessment in whom tube potential and tube current were selected automatically by a combined automatic tube potential and tube current selection algorithm (APS-AEC) and compared them with 38 controls for whom tube voltage was selected according to standard body mass index (BMI) cutoffs and tube current was selected using automatic exposure control (BMI-AEC). Controls were matched for BMI, heart rate, heart rhythm, sex, acquisition mode, and indication for cardiac CTA. Image quality was assessed as contrast-to-noise ratio and signal-to-noise ratio in the proximal coronary arteries. Subjective reader assessment was also made. Total radiation dose (volume-weighted computed tomography dose index) was measured and compared between the 2 groups. In the study group, comparison was made with conventional BMI-guided prior protocols (site protocols and Society of Cardiovascular Computed Tomography recommendations) through disagreement analysis. RESULTS The APS-AEC cases received 29.8% lower overall radiation dose compared with controls (P=not significant). APS-AEC resulted in a significantly higher signal-to-noise ratio of the proximal coronary arteries (P<0.01) and contrast-to-noise ratio of the left main (P=0.01). In the study cases, the APS resulted in a change in tube potential versus site protocols and Society of Cardiovascular Computed Tomography recommendations in 45% (n=17) and 50% (n=19) of patients, respectively. CONCLUSION Automated tube potential selection software resulted in significantly improved objective image quality versus standard BMI-based methods of tube potential selection, without increased radiation doses.
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Woodard PK, White RD, Abbara S, Araoz PA, Cury RC, Dorbala S, Earls JP, Hoffmann U, Hsu JY, Jacobs JE, Javidan-Nejad C, Krishnamurthy R, Mammen L, Martin ET, Ryan T, Shah AB, Steiner RM, Vogel-Claussen J, White CS. ACR Appropriateness Criteria Chronic Chest Pain—Low to Intermediate Probability of Coronary Artery Disease. J Am Coll Radiol 2013; 10:329-34. [DOI: 10.1016/j.jacr.2013.01.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Accepted: 01/28/2013] [Indexed: 11/24/2022]
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IYENGAR S, ROOBOTTOM CA. Cardiac multidetector CT: method, indications and applications. IMAGING 2013. [DOI: 10.1259/imaging.20100065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Schneer S, Bachar GN, Atar E, Koronowski R, Dicker D. Evaluation of framingham and systematic coronary risk evaluation scores by coronary computed tomographic angiography in asymptomatic adults. Am J Cardiol 2013; 111:700-4. [PMID: 23273527 DOI: 10.1016/j.amjcard.2012.11.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2012] [Revised: 11/12/2012] [Accepted: 11/12/2012] [Indexed: 01/24/2023]
Abstract
Recently, coronary computed tomographic angiography (CCTA) was introduced as a tool for the early detection of coronary atherosclerosis. However, a disagreement exists regarding the accuracy of CCTA for the prediction of future cardiovascular risk compared to conventional clinical risks scores (e.g., Framingham and Systematic Coronary Risk Evaluation [SCORE] scores). The aim of the present study was to compare these 2 methods in asymptomatic Israeli subjects. CCTA was performed in 190 asymptomatic patients with ≥1 atherogenic risk factor as the primary screening tool for the presence of cardiovascular disease. The calcium score (CS) was measured in these subjects as a part of CCTA. In addition, the Framingham and SCORE scores were calculated, and statistical analysis using regression models was performed. The study included 190 subjects (84% men). The mean age was 55 ± 9.7 years. A significant correlation with the CS and plaque severity detected by CCTA was found when comparing the risk factors calculated by the SCORE and Framingham scores. A SCORE calculation of >2 versus <2 was related to a greater incidence of a CS >100 (42.9% vs 21.9; odds ratio [OR] 2.68, p = 0.001). When comparing high-risk (>4) and low-risk (<4) SCORE scores, the risk of atherosclerosis per CCTA was 50% versus 27.1% respectively (OR 2.7, p = 0.001). A high-risk Framingham (>20) versus low-risk Framingham (<20) score was related to a greater incidence of CS >100 (53.3% vs 28.6%; OR 3.18, p = 0.001). A high-risk versus low-risk SCORE score was related to greater plaque severity (79.2% vs 59.4%, respectively; OR 2.6, p = 0.001). A high-risk versus low-risk Framingham score was also related to greater plaque severity (93.3% vs 59%, respectively; OR 3.18, p = 0.001). The variables best predicting the severity of artery stenosis were age, gender, diabetes, and hypertension. In conclusion, the results of the present study indicate that the results of the Framingham and SCORE scores compared to those obtained using CCTA are good predictors of coronary artery disease. The use of these clinical scores seems important in identifying patients at risk of coronary atherosclerosis and treating them properly before the development of symptoms and also to help prevent the use of unnecessary invasive procedures.
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Mahler SA, Hiestand BC, Nwanaji-Enwerem J, Goff DC, Burke GL, Douglas Case L, Nicks B, Miller CD. Reduction in observation unit length of stay with coronary computed tomography angiography depends on time of emergency department presentation. Acad Emerg Med 2013; 20:231-9. [PMID: 23517254 DOI: 10.1111/acem.12094] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Revised: 09/28/2012] [Accepted: 10/29/2012] [Indexed: 12/29/2022]
Abstract
OBJECTIVES Prior studies demonstrating shorter length of stay (LOS) from coronary computed tomography angiography (CCTA) relative to stress testing in emergency department (ED) patients have not considered time of patient presentation. The objectives of this study were to determine whether low-risk chest pain patients receiving stress testing or CCTA have differences in ED plus observation unit (OU) LOS and if there are disparities in testing modality use, based on the time of patient presentation to the ED. METHODS The authors examined a cohort of low-risk chest pain patients evaluated in an ED-based OU using prospective and retrospective OU registry data. During the study period, stress testing and CCTA were both available from 08:00 to 17:00 hours. CCTA was not available on weekends, and therefore only subjects presenting on weekdays were included. Cox regression analysis was used to model the effect of testing modality (stress testing vs. CCTA) on OU LOS. Separate models were fit based on time of patient presentation to the ED using 4-hour blocks beginning at midnight. The primary independent variable was testing modality: stress testing or CCTA. Age, sex, and race were included as covariates. Logistic regression was used to model testing modality choice by time period adjusted for age, sex, and race. RESULTS Over the study period, 841 subjects presented Monday through Friday. Median LOS was 18.0 hours (interquartile range [IQR] = 11.7 to 22.9 hours). Objective cardiac testing was completed in 788 of 841 (94%) patients, with 496 (63%) receiving stress testing and 292 (37%) receiving CCTA. After age, race, and sex were adjusted for, patients presenting between 08:00 and 11:59 hours not only had a shorter LOS associated with CCTA (p < 0.0001), but also had a greater likelihood of being tested by CCTA (p = 0.001). None of the other time periods had significant differences in LOS or testing modality choice for CCTA relative to stress testing. CONCLUSIONS In an OU setting with weekday and standard business hours CCTA availability, CCTA testing was associated with shorter LOS among low-risk chest pain patients only in patients presenting to the ED between 08:00 and 11:59 hours. That time period was also associated with a greater likelihood of being tested by CCTA, suggesting that ED providers may have intuited the inability of CCTA to shorten LOS during other times.
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Affiliation(s)
- Simon A. Mahler
- Department of Epidemiology and Prevention; Wake Forest School of Medicine; Winston-Salem NC
- Department of Emergency Medicine; Wake Forest School of Medicine; Winston-Salem NC
| | - Brian C. Hiestand
- Department of Emergency Medicine; Wake Forest School of Medicine; Winston-Salem NC
| | | | - David C. Goff
- Department of Epidemiology and Prevention; Wake Forest School of Medicine; Winston-Salem NC
| | - Gregory L. Burke
- Public Health Sciences; Wake Forest School of Medicine; Winston-Salem NC
| | - L. Douglas Case
- Department of Biostatistics; Wake Forest School of Medicine; Winston-Salem NC
| | - Bret Nicks
- Department of Emergency Medicine; Wake Forest School of Medicine; Winston-Salem NC
| | - Chadwick D. Miller
- Department of Emergency Medicine; Wake Forest School of Medicine; Winston-Salem NC
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Kashiwagi M, Tanaka A, Shimada K, Kitabata H, Komukai K, Nishiguchi T, Ozaki Y, Tanimoto T, Kubo T, Hirata K, Mizukoshi M, Akasaka T. Distribution, frequency and clinical implications of napkin-ring sign assessed by multidetector computed tomography. J Cardiol 2013; 61:399-403. [PMID: 23452399 DOI: 10.1016/j.jjcc.2013.01.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Revised: 12/24/2012] [Accepted: 01/10/2013] [Indexed: 11/24/2022]
Abstract
BACKGROUND Plaque rupture and secondary thrombus formation play key roles in the onset of acute coronary syndrome (ACS). Plaques showing the napkin-ring sign in multidetector computed tomography (MDCT) have been reported as thin-cap fibroatheroma that is recognized as a precursor lesion for plaque rupture. The purpose of this study was to investigate distribution and frequency of napkin-ring sign and its relationship to features indicating coronary plaque vulnerability on MDCT in patients with coronary artery disease. METHODS We enrolled 273 patients with ACS (n=61) or stable angina pectoris (SAP, n=212) who were assessed by MDCT. The definition of the napkin-ring sign was the presence of a ring of high attenuation and the CT attenuation of a ring presenting higher than those of the adjacent plaque and no greater than 130HU. RESULTS The culprit plaques with the napkin-ring sign show higher remodeling index and lower CT attenuation (1.15±0.12 vs. 1.02±0.12, p<0.01 and 39.9±22.8 vs. 72.7±26.6, p<0.01, respectively). Napkin-ring sign at culprit lesions was more frequent in patients with ACS than those with SAP (49.0% vs. 11.2%, p<0.01). Moreover, napkin-ring sign at non-culprit lesions was more frequently observed in ACS patients compared with SAP patients (12.7% vs. 2.8%, p<0.01). The distribution of the napkin-ring sign in the right coronary arteries and left circumflex arteries of our population was relatively even, whereas the napkin-ring sign in the left anterior descending artery was common in the proximal sites (p<0.01). CONCLUSIONS The napkin-ring sign assessed by MDCT represents similar clinical features of fibroatheroma. MDCT could contribute to the search for fibroatheroma.
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Affiliation(s)
- Manabu Kashiwagi
- Department of Cardiovascular Medicine, Wakayama Medical University, Wakayama, Japan.
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Triage of patients presenting with chest pain to the emergency department: implementation of coronary CT angiography in a large urban health care system. AJR Am J Roentgenol 2013; 200:57-65. [PMID: 23255742 DOI: 10.2214/ajr.12.8808] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE There is growing evidence supporting the use of coronary CT angiography (CTA) to triage patients in the emergency department (ED) with acute chest pain and low risk of acute coronary syndrome (ACS). We hypothesized that coronary CTA can guide early management and safely discharge patients by introducing a dedicated patient management protocol. SUBJECTS AND METHODS We conducted a prospective cohort study in three EDs of a large health care system (> 1300 beds). Five hundred twenty-nine patients (mean age, 52.1 years; 56% women) with chest pain, negative cardiac enzyme results, normal or nondiagnostic ECG findings, and a thrombolysis in myocardial infarction (TIMI) risk score of 2 or less were admitted and underwent CTA. A new dedicated chest pain triage protocol (levels 1-5) was implemented. On the basis of CTA findings, patients were stratified into one of the following four groups: 0, low (negative CTA findings); 1, mild (1-49% stenosis); 2, moderate (50-69% stenosis); or 3, severe (≥ 70% stenosis) risk of ACS. Outcome measures included major adverse cardiac events (MACEs) during the first 30 days after CTA, downstream testing results, and length of stay (LOS). LOS was compared before and after implementation of our chest pain triage protocol. RESULTS Three hundred seventeen patients (59.9%) with negative CTA findings and 151 (28.5%) with mild stenosis were discharged from the ED with a very low downstream testing rate and a very low MACE rate (negative predictive value = 99.8%). Twenty-five patients (4.7%) had moderate stenosis (n = 17 undergoing further testing). Thirty-six patients (6.8%) had stenosis of 70% or greater by CTA (n = 34 positive by invasive angiography or SPECT-myocardial perfusion imaging). The sensitivity of CTA was 94%. The rate of MACEs in patients with stenosis of 70% or greater (8.3%) was significantly higher (p < 0.001) than in patients with negative CTA findings (0%) or those with mild stenosis (0.2%). A 51% decrease in LOS-from 28.8 to 14.0 hours--was noted after implementation of the dedicated chest pain protocol (p < 0.001). CONCLUSION Chest pain patients with negative or mild nonobstructive CTA findings can be safely discharged from the ED without further testing. Implementation of a dedicated chest pain triage protocol is critical for the success of a coronary CTA program.
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Abstract
OBJECTIVE Echocardiography, radionuclide myocardial perfusion imaging (MPI), and coronary CT angiography (CTA) are the three main imaging techniques used in the emergency department for the diagnosis of acute coronary syndrome (ACS). The purpose of this article is to quantitatively examine existing evidence about the diagnostic performance of these imaging tests in this setting. CONCLUSION Our systematic search of the medical literature showed no significant difference between the modalities for the detection of ACS in the emergency department. There was a slight, positive trend favoring coronary CTA. Given the absence of large differences in diagnostic performance, practical aspects such as local practice, expertise, medical facilities, and individual patient characteristics may be more important.
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66
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Hoffmann U, Venkatesh V, White RD, Woodard PK, Carr JJ, Dorbala S, Earls JP, Jacobs JE, Mammen L, Martin ET, Ryan T, White CS. ACR Appropriateness Criteria(®) acute nonspecific chest pain-low probability of coronary artery disease. J Am Coll Radiol 2013; 9:745-50. [PMID: 23025871 DOI: 10.1016/j.jacr.2012.06.032] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2012] [Accepted: 06/28/2012] [Indexed: 11/28/2022]
Abstract
This document outlines the usefulness of available diagnostic imaging for patients without known coronary artery disease and at low probability for having coronary artery disease who do not present with classic signs, symptoms, or electrocardiographic abnormalities indicating acute coronary syndrome but rather with nonspecific chest pain leading to a differential diagnosis, including pulmonary, gastrointestinal, or musculoskeletal pathologies. A number of imaging modalities are available to evaluate the broad spectrum of possible pathologies in these patients, such as chest radiography, multidetector CT, MRI, ventilation-perfusion scans, cardiac perfusion scintigraphy, transesophageal and transthoracic echocardiography, PET, spine and rib radiography, barium esophageal and upper gastrointestinal studies, and abdominal ultrasound. It is considered appropriate to start the assessment of these patients with a low-cost, low-risk diagnostic test such as a chest x-ray. Contrast-enhanced gated cardiac and ungated thoracic multidetector CT as well as transthoracic echocardiography are also usually considered as appropriate in the evaluation of these patients as a second step if necessary. A number of rest and stress single-photon emission CT myocardial perfusion imaging, ventilation-perfusion scanning, aortic and chest MR angiographic, and more specific x-ray and abdominal examinations may be appropriate as a third layer of testing, whereas MRI of the heart or coronary arteries and invasive testing such as transesophageal echocardiography or selective coronary angiography are not considered appropriate in these patients. Given the low risk of these patients, it is mandated to minimize radiation exposure as much as possible using advanced and appropriate testing protocols. The ACR Appropriateness Criteria® are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
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Affiliation(s)
- Udo Hoffmann
- Massachusetts General Hospital, Boston, MA, USA.
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67
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D'Ascenzo F, Cerrato E, Biondi-Zoccai G, Omedè P, Sciuto F, Presutti DG, Quadri G, Raff GL, Goldstein JA, Litt H, Frati G, Reed MJ, Moretti C, Gaita F. Coronary computed tomographic angiography for detection of coronary artery disease in patients presenting to the emergency department with chest pain: a meta-analysis of randomized clinical trials. Eur Heart J Cardiovasc Imaging 2012; 14:782-9. [PMID: 23221314 DOI: 10.1093/ehjci/jes287] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
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68
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An initial randomised study assessing free-breathing CCTA using 320-detector CT. Eur Radiol 2012; 23:1199-209. [PMID: 23138388 DOI: 10.1007/s00330-012-2703-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Revised: 09/25/2012] [Accepted: 10/11/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVES To evaluate the feasibility of free-breathing coronary computed tomography angiography (CCTA) in adults using with a 320-detector multidetector CT (MDCT). METHODS In 74 patients who underwent CCTA, 37 CCTA examinations were performed during free-breathing, and the remaining 37 CCTA examinations were produced with the standard breath-holding method. The quality scores for 16 segments of all coronary arteries were analysed and defined as: 1 (excellent), 2 (good), and 3 (poor). The signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), and effective radiation dose of each image were compared between the two methods. RESULTS No significant differences were observed in the quality scores between the breath-holding and free-breathing methods (1.10 ± 0.31 vs. 1.12 ± 0.33; P = 0.443). The SNR and CNR were not significantly different between the two methods. The overall mean effective radiation dose revealed no significant difference between the two methods (P = 0.585). CONCLUSIONS Free-breathing CCTA using 320-detector MDCT showed no significant difference in image quality compared with standard breath-holding CCTA. For patients with difficulties of breath-holding or non-negligible apnoea-related heart rate variability, free-breathing CCTA can be an alternative solution for coronary artery evaluation. KEY POINTS • Cardiac CT is becoming widely used and some patients are inevitably breathless. • Multidetector CT (e.g. 320) offers new opportunities for the breathless patient. • Free breathing images yielded similar image quality to those obtained using breath-holding. • However, a possibility of higher radiation dose precludes its routine application.
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Lee CP, Hoffmann U, Bamberg F, Brown DF, Chang Y, Swap C, Parry BA, Nagurney JT. Emergency physician estimates of the probability of acute coronary syndrome in a cohort of patients enrolled in a study of coronary computed tomographic angiography. CAN J EMERG MED 2012; 14:147-56. [PMID: 22575295 DOI: 10.2310/8000.2012.110485] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Little information exists regarding how accurately emergency physicians (EPs) predict the probability of acute coronary syndrome (ACS). Our objective was to determine if EPs can accurately predict ACS in a prospectively identified cohort of emergency department (ED) patients who met enrolment criteria for a study of coronary computed tomographic angiography (CCTA) and were admitted for a "rule out ACS" protocol. METHODS A prospective observational pilot study in an academic medical centre was carried out. EPs caring for patients with chest pain provided whole-number estimates of the probability of ACS after clinical review. This substudy was part of the now published Rule Out Myocardial Infarction/Ischemia Using Computer Assisted Tomography (ROMICAT) study, a study of CCTA and admission of patients for a rule out ACS protocol after a nondiagnostic evaluation. Predictions were grouped into probability groups based on the validated Goldman criteria. ACS was determined by an adjudication committee using American Heart Association/American College of Cardiology/European Society of Cardiology guidelines. RESULTS A total of 334 predictions were obtained for a study population with a mean age of 54 (SD 12) years, 63% of whom were male. There were 35 ACS events. EPs predicted ACS better than by chance, and increasingly higher estimates were associated with a higher incidence of ACS (p = 0.0004). The percentage of patients with ACS was 0%, 6%, 7%, and 17%, respectively, for very low, low, intermediate, and high probability groups. EPs' estimates had a sensitivity of 63% using a > 20% probability of ACS to define a positive test. Lowering this threshold to > 7% to define a test as positive increased the sensitivity of physician estimates to 89% but lowered specificity from 65% to 24%. CONCLUSION Our data suggest that for a selected ED cohort meeting eligibility criteria for a study of CCTA, EPs predict ACS better than by chance, with an increasing proportion of patients proving to have ACS with increasing probability estimates. Lowering the estimate threshold does not result in an overall sensitivity level that is sufficient to send patients home from the ED and is associated with a poor specificity.
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Affiliation(s)
- Chuen Peng Lee
- Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital, Singapore
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70
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Comparison of image characteristics of plaques in culprit coronary arteries by 64 slice CT and intravascular ultrasound in acute coronary syndromes. Int J Cardiol 2012; 160:119-26. [DOI: 10.1016/j.ijcard.2011.04.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Revised: 03/26/2011] [Accepted: 04/14/2011] [Indexed: 11/20/2022]
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71
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Coronary Computed Tomography Angiography: Costs and Current Reimbursement Status. CURRENT CARDIOVASCULAR IMAGING REPORTS 2012. [DOI: 10.1007/s12410-012-9158-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Armstrong EJ, Kulkarni AR, Hoffmayer KS, Bhave PD, MacGregor JS, Hsue P, Stein JC, Kinlay S, Ganz P, McCabe JM. Delaying primary percutaneous coronary intervention for computed tomographic scans in the emergency department. Am J Cardiol 2012; 110:345-9. [PMID: 22534052 DOI: 10.1016/j.amjcard.2012.03.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Revised: 03/21/2012] [Accepted: 03/21/2012] [Indexed: 11/19/2022]
Abstract
Patients presenting with suspected ST-segment elevation myocardial infarction (STEMI) may have important alternative diagnoses (e.g., aortic dissection, pulmonary emboli) or safety concerns for STEMI management (e.g., head trauma). Computed tomographic (CT) scanning may help in identifying these alternative diagnoses but may also needlessly delay primary percutaneous coronary intervention (PCI). We analyzed the ACTIVATE-SF Registry, which consists of consecutive patients with a clinical diagnosis of STEMI admitted to the emergency departments of 2 urban hospitals. Of 410 patients with a suspected diagnosis of STEMI, 45 (11%) underwent CT scanning before primary PCI. Presenting electrocardiograms, baseline risk factors, and presence of an angiographic culprit vessel were similar in those with and without CT scanning before PCI. Only 2 (4%) of these CT scans changed clinical management by identifying a stroke. Patients who underwent CT scanning had far longer door-to-balloon times (median 166 vs 75 minutes, p <0.001) and higher in-hospital mortality (20% vs 7.8%, p = 0.006). After multivariate adjustment, CT scanning in the emergency department before primary PCI remained independently associated with longer door-to-balloon times (100% longer, 95% confidence interval 60 to 160, p <0.001) but was no longer associated with mortality (odds ratio 1.4, p = 0.5). In conclusion, CT scanning before primary PCI rarely changed management and was associated with significant delays in door-to-balloon times. More judicious use of CT scanning should be considered.
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Affiliation(s)
- Ehrin J Armstrong
- Division of Cardiovascular Medicine, University of California, Davis, Davis, CA, USA
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74
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Ferencik M, Schlett CL, Bamberg F, Truong QA, Nichols JH, Pena AJ, Shapiro MD, Rogers IS, Seneviratne S, Parry BA, Cury RC, Brady TJ, Brown DF, Nagurney JT, Hoffmann U. Comparison of traditional cardiovascular risk models and coronary atherosclerotic plaque as detected by computed tomography for prediction of acute coronary syndrome in patients with acute chest pain. Acad Emerg Med 2012; 19:934-42. [PMID: 22849339 DOI: 10.1111/j.1553-2712.2012.01417.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
OBJECTIVES The objective was to determine the association of four clinical risk scores and coronary plaque burden as detected by computed tomography (CT) with the outcome of acute coronary syndrome (ACS) in patients with acute chest pain. The hypothesis was that the combination of risk scores and plaque burden improved the discriminatory capacity for the diagnosis of ACS. METHODS The study was a subanalysis of the Rule Out Myocardial Infarction Using Computer-Assisted Tomography (ROMICAT) trial-a prospective observational cohort study. The authors enrolled patients presenting to the emergency department (ED) with a chief complaint of acute chest pain, inconclusive initial evaluation (negative biomarkers, nondiagnostic electrocardiogram [ECG]), and no history of coronary artery disease (CAD). Patients underwent contrast-enhanced 64-multidetector-row cardiac CT and received standard clinical care (serial ECG, cardiac biomarkers, and subsequent diagnostic testing, such as exercise treadmill testing, nuclear stress perfusion imaging, and/or invasive coronary angiography), as deemed clinically appropriate. The clinical providers were blinded to CT results. The chest pain score was calculated and the results were dichotomized to ≥10 (high-risk) and <10 (low-risk). Three risk scores were calculated, Goldman, Sanchis, and Thrombolysis in Myocardial Infarction (TIMI), and each patient was assigned to a low-, intermediate-, or high-risk category. Because of the low number of subjects in the high-risk group, the intermediate- and high-risk groups were combined into one. CT images were evaluated for the presence of plaque in 17 coronary segments. Plaque burden was stratified into none, intermediate, and high (zero, one to four, and more than four segments with plaque). An outcome panel of two physicians (blinded to CT findings) established the primary outcome of ACS (defined as either an acute myocardial infarction or unstable angina) during the index hospitalization (from the presentation to the ED to the discharge from the hospital). Logistic regression modeling was performed to examine the association of risk scores and coronary plaque burden to the outcome of ACS. Unadjusted models were individually fitted for the coronary plaque burden and for Goldman, Sanchis, TIMI, and chest pain scores. In adjusted analyses, the authors tested whether the association between risk scores and ACS persisted after controlling for the coronary plaque burden. The prognostic discriminatory capacity of the risk scores and plaque burden for ACS was assessed using c-statistics. The differences in area under the receiver-operating characteristic curve (AUC) and c-statistics were tested by performing the -2 log likelihood ratio test of nested models. A p value <0.05 was considered statistically significant. RESULTS Among 368 subjects, 31 (8%) subjects were diagnosed with ACS. Goldman (AUC = 0.61), Sanchis (AUC = 0.71), and TIMI (AUC = 0.63) had modest discriminatory capacity for the diagnosis of ACS. Plaque burden was the strongest predictor of ACS (AUC = 0.86; p < 0.05 for all comparisons with individual risk scores). The combination of plaque burden and risk scores improved prediction of ACS (plaque + Goldman AUC = 0.88, plaque + Sanchis AUC = 0.90, plaque + TIMI AUC = 0.88; p < 0.01 for all comparisons with coronary plaque burden alone). CONCLUSIONS Risk scores (Goldman, Sanchis, TIMI) have modest discriminatory capacity and coronary plaque burden has good discriminatory capacity for the diagnosis of ACS in patients with acute chest pain. The combined information of risk scores and plaque burden significantly improves the discriminatory capacity for the diagnosis of ACS.
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Affiliation(s)
- Maros Ferencik
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
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Foster TA, Shapiro MD. The ‘Triple Rule Out’ CT Angiogram for Acute Chest Pain: Should it be Done, and If So, How? CURRENT CARDIOVASCULAR IMAGING REPORTS 2012. [DOI: 10.1007/s12410-012-9152-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Hascoët S, Bongard V, Chabbert V, Marachet MA, Rousseau H, Charpentier S, Bouisset F, Honton B, Lairez O, Marchal P, Berry M, Carrié D, Galinier M, Elbaz M. Early triage of emergency department patients with acute coronary syndrome: Contribution of 64-slice computed tomography angiography. Arch Cardiovasc Dis 2012; 105:338-46. [DOI: 10.1016/j.acvd.2012.04.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Revised: 04/08/2012] [Accepted: 04/18/2012] [Indexed: 10/28/2022]
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Implications of 25% to 50% coronary stenosis with cardiac computed tomographic angiography in ED patients. Am J Emerg Med 2012; 30:597-605. [DOI: 10.1016/j.ajem.2011.02.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2011] [Revised: 02/15/2011] [Accepted: 02/17/2011] [Indexed: 11/19/2022] Open
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Fernandez-Friera L, Garcia-Alvarez A, Guzman G, Garcia MJ. Coronary CT and the coronary calcium score, the future of ED risk stratification? Curr Cardiol Rev 2012; 8:86-97. [PMID: 22708911 PMCID: PMC3406277 DOI: 10.2174/157340312801784989] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2010] [Revised: 08/17/2011] [Accepted: 09/01/2011] [Indexed: 01/07/2023] Open
Abstract
Accurate and efficient evaluation of acute chest pain remains clinically challenging because traditional diagnostic modalities have many limitations. Recent improvement in non-invasive imaging technologies could potentially improve both diagnostic efficiency and clinical outcomes of patients with acute chest pain while reducing unnecessary hospitalizations. However, there is still controversy regarding much of the evidence for these technologies. This article reviews the role of coronary artery calcium score and the coronary computed tomography in the assessment of individual coronary risk and their usefulness in the emergency department in facilitating appropriate disposition decisions. The evidence base and clinical applications for both techniques are also described, together with cost- effectiveness and radiation exposure considerations.
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Affiliation(s)
- Leticia Fernandez-Friera
- Departamento de Cardiologia, Hospital Universitario Marqués de Valdecilla, Santander. Spain
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid. Spain
| | - Ana Garcia-Alvarez
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid. Spain
- Thorax Institute Cardiology Department, Hospital Clinic, Barcelona, Spain
| | - Gabriela Guzman
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid. Spain
- Hospital La Paz, Madrid. Spain
| | - Mario J Garcia
- Montefiore Heart Center-Albert Einstein School of Medicine. New York
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Kang KW, Chang HJ, Shim H, Kim YJ, Choi BW, Yang WI, Shim JY, Ha J, Chung N. Feasibility of an automatic computer-assisted algorithm for the detection of significant coronary artery disease in patients presenting with acute chest pain. Eur J Radiol 2012; 81:e640-6. [DOI: 10.1016/j.ejrad.2012.01.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2011] [Revised: 12/24/2011] [Accepted: 01/10/2012] [Indexed: 11/25/2022]
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80
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Samad Z, Hakeem A, Mahmood SS, Pieper K, Patel MR, Simel DL, Douglas PS. A meta-analysis and systematic review of computed tomography angiography as a diagnostic triage tool for patients with chest pain presenting to the emergency department. J Nucl Cardiol 2012; 19:364-76. [PMID: 22322526 DOI: 10.1007/s12350-012-9520-2] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND To assess clinical utility of computed tomography angiography (CTA) in the diagnosis of chest pain patients presenting to emergency departments (EDs), we conducted a meta-analysis of CTA in patients with suspected acute coronary syndromes (ACSs). METHODS 386 studies were identified on initial review of literature. Inclusion criteria were: (1) prospective study with ≥1 month follow-up, (2) use of CTA in the ED setting, (3) use of ACC/AHA definitions for ACS and robust assessment of major adverse cardiac events, (4) ≥30 patients, and (5) study population with initial non-diagnostic ECGs and negative biomarkers. RESULTS Nine studies (N = 1349) formed the data set. The pooled patient population was 52 ± 2 years of age, 51% male, with low to intermediate pretest probability for ACS. Risk factors included 12% diabetes, 42% hypertension, 35% smokers, 29% had hyperlipidemia, and 7% known CAD. ACS was subsequently diagnosed in 10% of patients. The bivariate summary estimate of sensitivity of CTA for ACS diagnosis was 95% (95% CI 88-100) and specificity was 87% (95% CI 83-92), yielding a negative likelihood ratio of 0.06 (95% CI 0-0.14) and positive likelihood ratio of 7.4 (95% CI 4.8-10). The 30-day event rate included no deaths and no additional MIs. CONCLUSION Coronary CTA demonstrates a high sensitivity and a low negative likelihood ratio of 0.06, and is effective in ruling out the presence of ACS in low to intermediate risk patients presenting to the ED with acute chest pain.
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Affiliation(s)
- Zainab Samad
- Division of Cardiovascular Medicine, Duke University Medical Center (DUMC), Durham, NC 27710, USA.
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81
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Achenbach S, Barkhausen J, Beer M, Beerbaum P, Dill T, Eichhorn J, Fratz S, Gutberlet M, Hoffmann M, Huber A, Hunold P, Klein C, Krombach G, Kreitner KF, Kühne T, Lotz J, Maintz D, Marholdt H, Merkle N, Messroghli D, Miller S, Paetsch I, Radke P, Steen H, Thiele H, Sarikouch S, Fischbach R. Konsensusempfehlungen der DRG/DGK/DGPK zum Einsatz der Herzbildgebung mit Computertomographie und Magnetresonanztomographie. KARDIOLOGE 2012. [DOI: 10.1007/s12181-012-0417-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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82
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Schlett CL, Ferencik M, Kriegel MF, Bamberg F, Ghoshhajra BB, Joshi SB, Nagurney JT, Fox CS, Truong QA, Hoffmann U. Association of pericardial fat and coronary high-risk lesions as determined by cardiac CT. Atherosclerosis 2012; 222:129-34. [PMID: 22417843 DOI: 10.1016/j.atherosclerosis.2012.02.029] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2011] [Revised: 02/15/2012] [Accepted: 02/16/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Pericardial adipose tissue (PAT) is a pathogenic fat depot associated with coronary atherosclerosis and cardiovascular events. We hypothesized that higher PAT is associated with coronary high-risk lesions as determined by cardiac CT. METHODS We included 358 patients (38% female; median age 51 years) who were admitted to the ED with acute chest pain and underwent 64-slice CT angiography. The cardiac CT data sets were assessed for presence and morphology of CAD and PAT. Coronary high-risk lesions were defined as >50% luminal narrowing and at least two of the following characteristics: positive remodeling, low-density plaque, and spotty calcification. PAT was defined as any pixel with CT attenuation of -190 to -30 HU within the pericardial sac. RESULTS Based on cardiac CT, 50% of the patients (n=180) had no CAD, 46% (n=165) had CAD without high-risk lesions, and 13 patients had CAD with high-risk lesions. The median PAT in patients with high-risk lesions was significantly higher compared to patients without high-risk lesions and without any CAD (151.9 [109.0-179.4]cm(3) vs. 110.0 [81.5-137.4]cm(3), vs. 74.8 [58.2-111.7]cm(3), respectively p=0.04 and p<0.0001). These differences remained significant after adjusting for traditional risk factors including BMI (all p<0.05). The area under the ROC curve for the identification of high-risk lesions was 0.756 in a logistic regression model with PAT as a continuous predictor. CONCLUSION PAT volume is nearly twice as high in patients with high-risk coronary lesions as compared to those without CAD. PAT volume is significantly associated with high risk coronary lesion morphology independent of clinical characteristics and general obesity.
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Affiliation(s)
- Christopher L Schlett
- Cardiac MR, PET, CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02214, USA
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83
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Scheffel H, Stolzmann P, Schlett CL, Engel LC, Major GP, Károlyi M, Do S, Maurovich-Horvat P, Hoffmann U. Coronary artery plaques: cardiac CT with model-based and adaptive-statistical iterative reconstruction technique. Eur J Radiol 2011; 81:e363-9. [PMID: 22197733 DOI: 10.1016/j.ejrad.2011.11.051] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2011] [Accepted: 11/25/2011] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To compare image quality of coronary artery plaque visualization at CT angiography with images reconstructed with filtered back projection (FBP), adaptive statistical iterative reconstruction (ASIR), and model based iterative reconstruction (MBIR) techniques. METHODS The coronary arteries of three ex vivo human hearts were imaged by CT and reconstructed with FBP, ASIR and MBIR. Coronary cross-sectional images were co-registered between the different reconstruction techniques and assessed for qualitative and quantitative image quality parameters. Readers were blinded to the reconstruction algorithm. RESULTS A total of 375 triplets of coronary cross-sectional images were co-registered. Using MBIR, 26% of the images were rated as having excellent overall image quality, which was significantly better as compared to ASIR and FBP (4% and 13%, respectively, all p<0.001). Qualitative assessment of image noise demonstrated a noise reduction by using ASIR as compared to FBP (p<0.01) and further noise reduction by using MBIR (p<0.001). The contrast-to-noise-ratio (CNR) using MBIR was better as compared to ASIR and FBP (44±19, 29±15, 26±9, respectively; all p<0.001). CONCLUSIONS Using MBIR improved image quality, reduced image noise and increased CNR as compared to the other available reconstruction techniques. This may further improve the visualization of coronary artery plaque and allow radiation reduction.
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Affiliation(s)
- Hans Scheffel
- Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02144, USA
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84
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Takakuwa KM, Keith SW, Estepa AT, Shofer FS. A meta-analysis of 64-section coronary CT angiography findings for predicting 30-day major adverse cardiac events in patients presenting with symptoms suggestive of acute coronary syndrome. Acad Radiol 2011; 18:1522-8. [PMID: 22055795 DOI: 10.1016/j.acra.2011.08.013] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2011] [Revised: 08/15/2011] [Accepted: 09/11/2011] [Indexed: 11/19/2022]
Abstract
RATIONALE AND OBJECTIVES To determine the accuracy of 64-section coronary computed tomography angiography (CCTA) in predicting 30 day major adverse cardiac events (MACE) for patients presenting with symptoms concerning for acute coronary syndrome (ACS). MATERIALS AND METHODS Electronic databases between January 1, 2005, and May, 1, 2011, and reference lists from relevant published research articles were searched. We included studies on adult patients who presented with active symptoms suggestive of ACS, had immediate 64-section CCTA performed and were assessed for MACE at a minimum of 30 days past their initial presentation. Studies had to report or provide sufficient detail to determine sensitivity, specificity, positive predictive value, and negative predictive value in relation to MACE using a 50% diameter stenosis as cutoff criterion for coronary artery disease. RESULTS Nine studies were included for a total of 1559 patients studied (42.3% women, mean age 51.9 ± 10.6). Patients ranged from low to intermediate risk for ACS. All had initial inconclusive electrocardiograms and negative cardiac biomarker results. A total of 14.8% of patients had a positive CCTA result. The pooled sensitivity was 93.3% (95% CI 88.3%-96.6%), specificity was 89.9% (95% CI 88.3%-91.3%), positive predictive value was 48.1% (95% CI 42.5%-53.8%), and negative predictive value was 99.3% (95% CI 98.7%-99.6%). CONCLUSION Sixty-four section CCTA had a 99.3% negative predictive value in excluding MACE for 30 days after initial symptom presentation in 85.2% of our study population. Although the value of 64-section CCTA is best for identifying patients who can safely be discharged home, it is less useful for patients who have positive results.
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Affiliation(s)
- Kevin M Takakuwa
- Thomas Jefferson University Hospital, 111 S. 11th Street, Philadelphia, PA 19107, USA.
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Roobottom C, Mitchell G, Iyengar S. The role of non-invasive imaging in patients with suspected acute coronary syndrome. Br J Radiol 2011; 84 Spec No 3:S269-79. [PMID: 22723534 PMCID: PMC3473914 DOI: 10.1259/bjr/57084479] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
This article gives an overview of the role of imaging in the diagnosis and management of acute coronary syndrome.
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Affiliation(s)
- C Roobottom
- Peninsula Medical School, University of Plymouth, Derriford Hospital, 1 Derriford Road, Plymouth, UK.
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86
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Ilgen JS, Manini AF, Hoffmann U, Noble VE, Giraldez E, Nualpring S, Bohan JS. Prognostic utility of the acute cardiac ischemia time-insensitive predictive instrument (ACI-TIPI). Int J Emerg Med 2011; 4:49. [PMID: 21801452 PMCID: PMC3163517 DOI: 10.1186/1865-1380-4-49] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2010] [Accepted: 07/31/2011] [Indexed: 11/17/2022] Open
Abstract
Background We sought to evaluate the test characteristics of the acute cardiac ischemia time-insensitive predictive instrument (ACI-TIPI) in relation to 30-day major adverse cardiac events (MACE) among patients who presented to the Emergency Department with symptoms suggestive of an acute coronary syndrome. We then examined the test characteristics of various dichotomous ACI-TIPI cut points. Methods We prospectively recruited a cohort of Emergency Department (ED) patients with acute chest pain at two urban university hospitals between June and September 2006. Upon enrollment, baseline demographics and cardiac risk factors were collected. An electrocardiogram (ECG) was performed and analyzed with the built-in ACI-TIPI multiple regression model software. An ACI-TIPI probability score was recorded for each patient. Diagnostic test characteristics of ACI-TIPI for MACE (non-ST elevation myocardial infarction (NSTEMI), percutaneous coronary intervention, coronary artery bypass grafting, and all-cause mortality) within 30 days were determined. Results Of 144 patients enrolled (mean age 59.1 ± 14.1 years, 59% men), 19 (13%) patients suffered MACE within 30 days. Receiver-operating characteristics (ROC) for ACI-TIPI yielded a c-statistic of 0.69 (95% CI 0.59-0.80, p < 0.01). An ACI-TIPI score of ≥ 20 had 100% sensitivity (95% CI 82-100), 100% negative predictive value (95% CI 86-100), and 21% specificity (14-31%). Conclusions These preliminary results suggest that, while ACI-TIPI has limited discriminatory value for MACE overall, a score of < 20 may have 30-day prognostic utility to allow for safe outpatient management in patients with acute chest pain.
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87
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Bastarrika G, Schoepf UJ. [Radiologists in the emergency department: when and how to use multislice CT]. RADIOLOGIA 2011; 53 Suppl 1:30-42. [PMID: 21803386 DOI: 10.1016/j.rx.2011.02.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2010] [Revised: 02/14/2011] [Accepted: 02/26/2011] [Indexed: 11/19/2022]
Abstract
Chest pain is a challenging clinical problem in the emergency department. Despite advances in clinical diagnosis, many patients with atypical chest pain are needlessly hospitalized and others are mistakenly discharged. Faced with the specific clinical situation in which a patient has chest pain, an initially normal or inconclusive electrocardiogram, and normal cardiac biomarkers, multislice CT has proven useful for ruling out the conditions that involve the greatest morbidity and mortality and for establishing the cause of pain. This article reviews the current usefulness of multislice CT in the diagnostic workup of patients presenting at the emergency department with chest pain. We review the technique, define the most appropriate population, describe the acquisition protocols, and discuss the advantages and disadvantages of each study protocol.
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Affiliation(s)
- G Bastarrika
- Unidad de Imagen Cardiaca, Servicio de Radiología, Clínica Universidad de Navarra, Pamplona, Navarra, España.
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88
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Do S, Karl WC, Liang Z, Kalra M, Brady TJ, Pien HH. A decomposition-based CT reconstruction formulation for reducing blooming artifacts. Phys Med Biol 2011; 56:7109-25. [PMID: 22025109 DOI: 10.1088/0031-9155/56/22/008] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Cardiac computed tomography represents an important advancement in the ability to assess coronary vessels. The accuracy of these non-invasive imaging studies is limited, however, by the presence of calcium, since calcium blooming artifacts lead to an over-estimation of the degree of luminal narrowing. To address this problem, we have developed a unified decomposition-based iterative reconstruction formulation, where different penalty functions are imposed on dense objects (i.e. calcium) and soft tissue. The result is a quantifiable reduction in blooming artifacts without the introduction of new distortions away from the blooming observed in other methods. Results are shown for simulations, phantoms, ex vivo, and in vivo studies.
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Affiliation(s)
- Synho Do
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA.
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89
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Bezerra HG, Loureiro R, Irlbeck T, Bamberg F, Schlett CL, Rogers I, Blankstein R, Truong QA, Brady TJ, Cury RC, Hoffmann U. Incremental value of myocardial perfusion over regional left ventricular function and coronary stenosis by cardiac CT for the detection of acute coronary syndromes in high-risk patients: a subgroup analysis of the ROMICAT trial. J Cardiovasc Comput Tomogr 2011; 5:382-91. [PMID: 22146497 DOI: 10.1016/j.jcct.2011.10.004] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2011] [Revised: 10/11/2011] [Accepted: 10/19/2011] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To determine the incremental benefit of assessing myocardial perfusion defects (MPD) for acute coronary syndromes (ACS) over coronary and functional assessment by rest cardiac computed tomography (CT) in patients with acute chest pain. BACKGROUND Assessment of myocardial perfusion is feasible with cardiac CT; however, the diagnostic value of this assessment in patients at risk for ACS has not been demonstrated. METHODS The study included patients who presented to the emergency department with acute chest pain, nonischemic initial electrocardiogram (ECG), and negative cardiac biomarkers but had clinical suspicion for ACS and underwent invasive coronary angiography (ICA). Results were blinded to caregivers and patients. CT data sets were independently assessed for the presence of coronary plaque and stenosis, regional left ventricular function, and myocardial perfusion deficits by 2 blinded observers. Coronary angiography was assessed for the presence of stenosis, TIMI myocardial perfusion grade, and corrected TIMI frame count. The endpoint was ACS during index hospitalization. RESULTS We analyzed data from 35 subjects (69% male, mean age 58 ± 9 years) of whom 22 (63%) had ACS. The sensitivity and specificity of MPD for ACS were 86% (95% CI: 64%-96%) and 62% (95% CI: 32%-85%), respectively. Combined, MPD and RWMA assessment resulted in specificity and sensitivity of 86% (95% CI: 64%-96%) and 85% (95% CI: 54%-97%), respectively. Adding MPD and RWMA to the assessment for significant stenosis (>50%) resulted in a higher sensitivity of 91% (69-98%) and specificity of 85% (54-97%) and a significantly increased overall diagnostic accuracy when compared with assessment for stenosis (AUC: 0.88 vs 0.79; respectively, P = 0.02). Diagnostic accuracy of CT was not associated with impaired CTFC >40 or myocardial TIMI perfusion grade < 3. CONCLUSIONS Assessment of myocardial perfusion and regional wall motion abnormalities may enhance the ability of CT to detect ACS in patients with acute chest pain.
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Affiliation(s)
- Hiram G Bezerra
- Cardiac MR PET CT Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
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90
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Mortality risk in symptomatic patients with nonobstructive coronary artery disease: a prospective 2-center study of 2,583 patients undergoing 64-detector row coronary computed tomographic angiography. J Am Coll Cardiol 2011; 58:510-9. [PMID: 21777749 DOI: 10.1016/j.jacc.2010.11.078] [Citation(s) in RCA: 175] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2010] [Revised: 10/28/2010] [Accepted: 11/08/2010] [Indexed: 12/30/2022]
Abstract
OBJECTIVES We examined mortality risk in relation to extent and composition of nonobstructive plaques by 64-detector row coronary computed tomographic angiography (CCTA). BACKGROUND The prognostic significance of nonobstructive coronary artery plaques by CCTA is poorly understood. METHODS We prospectively evaluated consecutive adults from 2 centers undergoing 64-detector row CCTA without prior documented coronary artery disease (CAD) and without obstructive (≥50%) CAD by CCTA. Luminal diameter stenosis severity was classified for each segment as none (0%) or mild (1% to 49%), and plaque composition was classified as noncalcified, calcified, or mixed. RESULTS During 3.1 ± 0.5 years, 54 intermediate-term (≥90 days) deaths occurred among 2,583 patients (2.09%), with 4 early (<90 days) deaths. Adjusted for CAD risk factors, the presence of any nonobstructive plaque was associated with higher mortality (hazard ratio [HR]: 1.98, 95% confidence Interval [CI]: 1.06 to 3.69, p = 0.03), with the highest risk among those exhibiting nonobstructive CAD in 3 epicardial vessels (HR: 4.75, 95% CI: 2.10 to 10.75, p = 0.0002) or ≥5 segments (HR: 5.12, 95% CI: 2.16 to 12.10, p = 0.0002). Higher mortality for nonobstructive CAD was observed even among patients with low 10-year Framingham risk (3.4%, p < 0.0001) as well as those with no traditional, medically treatable CAD risk factors, including diabetes mellitus, hypertension, and dyslipidemia (6.7%, p < 0.0001). No independent relationship between plaque composition and incident mortality was observed. Importantly, patients without evident plaque experienced a low rate of incident death during follow-up (0.34%/year). CONCLUSIONS The presence and extent of nonobstructive plaques augment prediction of incident mortality beyond conventional clinical risk assessment.
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91
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Tandon V, Hall D, Yam Y, Al-Shehri H, Chen L, Tandon K, Beanlands RS, Wells GA, Ruddy TD, Chow BJW. Rates of downstream invasive coronary angiography and revascularization: computed tomographic coronary angiography vs. Tc-99m single photon emission computed tomography. Eur Heart J 2011; 33:776-82. [PMID: 21893487 DOI: 10.1093/eurheartj/ehr346] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS Computed tomographic coronary angiography (CTA) appears to be a useful modality for the detection of obstructive coronary artery disease (CAD). Recent data suggest that CTA may reduce the frequency of normal invasive coronary angiograms. However, there remains concern that the implementation of CTA could increase referrals to invasive coronary angiography (ICA). To further support the clinical acceptance of CTA, it is important to compare CTA to another accepted modality such as single photon emission computed tomography (SPECT). We followed a cohort of 64-slice CTA patients and a matched cohort of Tc-99m SPECT patients to determine downstream referrals for ICA and revascularization. METHODS AND RESULTS Consecutive CTA patients (without history of revascularization or cardiac transplantation) were prospectively enrolled and compared with a Tc-99m SPECT cohort (matched for age, gender, and Morise score). Each CTA and SPECT was evaluated for obstructive CAD and patients were followed for downstream ICA and revascularization. Of the 1221 patients in each cohort, 129 (10.6%) CTA patients and 125 (10.2%) SPECT patients were referred to ICA. Of those referred to ICA, obstructive CAD was confirmed in 105 (81.4%) CTA patients and in 88 (70.4%) SPECT patients. Differences in false positive rates were significantly lower in the CTA than the SPECT cohort (9.7 and 25.8%, respectively, P = 0.009). Rates of revascularization were similar in the CTA and SPECT cohorts (6.2 vs. 5.9%, respectively). CONCLUSION Compared with SPECT, CTA had similar referrals for ICA and revascularization rates but lower false positive rates. Computed tomographic coronary angiography appears to be a viable non-invasive diagnostic modality and does not appear to negatively impact upon ICA resources.
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Affiliation(s)
- Vikas Tandon
- Division of Cardiology, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, ON, Canada K1Y 4W7
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92
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Hassan A, Nazir SA, Alkadhi H. Technical challenges of coronary CT angiography: Today and tomorrow. Eur J Radiol 2011; 79:161-71. [PMID: 20227210 DOI: 10.1016/j.ejrad.2010.02.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2009] [Revised: 02/14/2010] [Accepted: 02/17/2010] [Indexed: 11/27/2022]
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Karakas M, Januzzi JL, Meyer J, Lee H, Schlett CL, Truong QA, Rottbauer W, Bamberg F, Dasdemir S, Hoffmann U, Koenig W. Copeptin Does Not Add Diagnostic Information to High-Sensitivity Troponin T in Low- to Intermediate-Risk Patients with Acute Chest Pain: Results from the Rule Out Myocardial Infarction by Computed Tomography (ROMICAT) Study. Clin Chem 2011; 57:1137-45. [DOI: 10.1373/clinchem.2010.160192] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
PURPOSE
Copeptin, a stable peptide derived from the AVP precursor, has been linked to presence and severity of myocardial ischemia. We sought to evaluate the predictive value of copeptin and its incremental value beyond that of high-sensitivity cardiac troponin T (hs-cTnT) in patients with acute chest pain and low to intermediate risk for acute coronary syndrome (ACS).
METHODS
We recruited patients who presented with acute chest pain to the emergency department and had a negative initial conventional troponin T test (<0.03 μg/L). In all patients, hs-cTnT and copeptin measurements were taken. Each patient also underwent cardiac computed tomography (CT) and coronary angiography.
RESULTS
Baseline copeptin concentrations, in contrast to hs-cTnT, were not significantly higher in patients with ACS than in those without (P = 0.24). hs-cTnT showed an earlier rise in patients with ACS than copeptin, when analyses were stratified by time. A copeptin concentration ≥7.38 pmol/L had a negative predictive value (NPV) of 94% and a sensitivity of 51%, whereas hs-cTnT (≥13.0 pg/mL) had a NPV of 96% and a sensitivity of 63%. The combination of copeptin and hs-cTnT resulted in a lower diagnostic accuracy than hs-cTnT alone. Finally, on cardiac CT, copeptin concentrations were not associated with coronary artery morphology, although they were related to the presence of left ventricular dysfunction (P = 0.02).
CONCLUSIONS
Among patients with acute chest pain and low to intermediate risk for ACS, copeptin concentrations are not independently predictive of ACS and do not add diagnostic value beyond that of hs-cTnT measurements.
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Affiliation(s)
- Mahir Karakas
- Department of Internal Medicine II–Cardiology, University of Ulm Medical Center, Ulm, Germany
| | | | - Julia Meyer
- Institute of Epidemiology, Helmholtz Zentrum München, German Research Center for Environmental Health, Neuherberg, Germany
| | | | | | - Quynh A Truong
- Division of Cardiology
- Department of Radiology, Massachusetts General Hospital, Boston, MA
| | - Wolfgang Rottbauer
- Department of Internal Medicine II–Cardiology, University of Ulm Medical Center, Ulm, Germany
| | - Fabian Bamberg
- Department of Radiology, Massachusetts General Hospital, Boston, MA
| | - Selcuk Dasdemir
- Department of Internal Medicine II–Cardiology, University of Ulm Medical Center, Ulm, Germany
| | - Udo Hoffmann
- Department of Radiology, Massachusetts General Hospital, Boston, MA
| | - Wolfgang Koenig
- Department of Internal Medicine II–Cardiology, University of Ulm Medical Center, Ulm, Germany
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Evaluation of acute chest pain in the emergency department: "triple rule-out" computed tomography angiography. Cardiol Rev 2011; 19:115-21. [PMID: 21464639 DOI: 10.1097/crd.0b013e31820f1501] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Triage of patients with acute, potentially life-threatening chest pain is one of the most important issues currently facing physicians in the emergency department. Appropriate evaluation of these patients begins with a skilled assessment of the individual patient's presenting symptoms and a careful review of his or her history and physical examination, often followed by serial recording of electrocardiograms and measurement of serum biochemical markers such as troponin and d-dimer. Stress testing, often accompanied by rest and stress myocardial perfusion imaging or echocardiography, and other diagnostic testing such as radionuclide lung scanning and invasive angiography may be required. A rapid, accurate, and cost-effective approach for the evaluation of emergency department patients with chest pain is needed. Development of newer generations of multidetector computed tomographic (MDCT) scanners, which are capable not only of performing high-quality noninvasive coronary angiography, but also concurrent aortic and pulmonary angiography, has led to increased use of MDCT for the so-called "triple rule out." MDCT is used for the detection of 3 of the most common life-threatening causes of chest pain-coronary artery disease, acute aortic syndrome, and pulmonary emboli. While triple rule-out protocol can be very useful and potentially cost effective when used appropriately, concern has risen regarding the overuse of this technology, which could expose patients to unnecessary radiation and iodinated contrast. The triple rule-out protocol is most appropriate for patients who present with acute chest pain, but are judged to have low to intermediate increased risk for acute coronary syndrome, and whose chest pain symptoms might also be attributed to acute pathologic conditions of the aorta or pulmonary arteries. MDCT should not be used as a routine screening procedure. Continued technical improvements in acquisition speed and spatial resolution of computed tomography images, and development of more efficient image reconstruction algorithms which reduce patient exposure to radiation and contrast, may result in increased popularity of MDCT for "triple rule-out."
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95
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Liew GYH, Feneley M, Worthley SG. Noninvasive Coronary Artery Imaging: Current Clinical Applications. Heart Lung Circ 2011; 20:425-37. [PMID: 21530393 DOI: 10.1016/j.hlc.2010.12.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2010] [Accepted: 12/13/2010] [Indexed: 01/01/2023]
Affiliation(s)
- Gary Y H Liew
- Cardiovascular Investigation Unit, Royal Adelaide Hospital, North Terrace, Adelaide, SA 5000, Australia.
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96
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Accuracy of dual-source CT to identify significant coronary artery disease in patients with uncontrolled hypertension presenting with chest pain: comparison with coronary angiography. Int J Cardiovasc Imaging 2011; 28:1173-80. [DOI: 10.1007/s10554-011-9907-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2011] [Accepted: 06/03/2011] [Indexed: 01/31/2023]
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97
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Integrated SPECT/CT for assessment of haemodynamically significant coronary artery lesions in patients with acute coronary syndrome. Eur J Nucl Med Mol Imaging 2011; 38:1917-25. [PMID: 21688049 DOI: 10.1007/s00259-011-1856-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2011] [Accepted: 05/26/2011] [Indexed: 10/18/2022]
Abstract
PURPOSE Early risk stratification in patients with non-ST elevation acute coronary syndromes (NSTE-ACS) is important since the benefit from more aggressive and costly treatment strategies is proportional to the risk of adverse clinical events. In the present study we assessed whether hybrid single photon emission computed tomography (SPECT)/coronary computed tomography angiography (CCTA) technology could be an appropriate tool in stratifying patients with NSTE-ACS. METHODS SPECT/CCTA was performed in 90 consecutive patients with NSTE-ACS. The Thrombolysis in Myocardial Infarction risk score (TIMI-RS) was used to classify patients as low- or high-risk. Imaging was performed using SPECT/CCTA to identify haemodynamically significant lesions defined as >50% stenosis on CCTA with a reversible perfusion defect on SPECT in the corresponding territory. RESULTS CCTA demonstrated at least one lesion with >50% stenosis in 35 of 40 high-risk patients (87%) as compared to 14 of 50 low-risk patients (35%; TIMI-RS<3; p<.0001). Of the 40 high-risk and 50 (16%) low-risk TIMI-RS patients, 16 (40%) and 8 (16%), respectively, had haemodynamically significant lesions (p=0.01). Patients defined as high-risk by a high TIMI-RS, a positive CCTA scan or both (n=45) resulted in a sensitivity of 95%, specificity of 49%, PPV of 35% and NPV of 97% for having haemodynamically significant coronary lesions. Those with normal perfusion were spared revascularization procedures, regardless of their TIMI-RS. CONCLUSION Noninvasive assessment of coronary artery disease by SPECT/CCTA may play an important role in risk stratification of patients with NSTE-ACS by better identifying the subgroup requiring intervention.
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98
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van der Giessen AG, Toepker MH, Donelly PM, Bamberg F, Schlett CL, Raffle C, Irlbeck T, Lee H, van Walsum T, Maurovich-Horvat P, Gijsen FJH, Wentzel JJ, Hoffmann U. Reproducibility, accuracy, and predictors of accuracy for the detection of coronary atherosclerotic plaque composition by computed tomography: an ex vivo comparison to intravascular ultrasound. Invest Radiol 2011; 45:693-701. [PMID: 20479650 DOI: 10.1097/rli.0b013e3181e0a541] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To determine the reproducibility, accuracy, and predictors of accuracy of computed tomography (CT) angiography to detect and characterize coronary atherosclerotic plaque as compared with intravascular ultrasound. METHODS Ten ex vivo human coronary arteries were imaged in a moving phantom by dual-source CT (collimation: 0.6 mm, reconstructed slice thickness: 0.4 mm) and intravascular ultrasound (IVUS). Coregistered cross-sections were assessed at 0.4 mm intervals for the presence and composition of atherosclerotic plaque (noncalcified, mixed, and calcified) on CT and IVUS by independent readers to determine reader agreement and diagnostic accuracy. Quantitative measurements of lumen and plaque area, plaque eccentricity, and intimal thickness on IVUS were used to determine predictors for the detection of noncalcified plaque by CT. RESULTS Within 1002 coregistered cross-sections, the interobserver agreement to detect plaque on CT was K = 0.48, K = 0.42, and K = 1.00 for noncalcified, mixed, and calcified plaque; respectively. The sensitivity and specificity of CT was 57% out of 84% for noncalcified, 32% of 92% for mixed, and 56% of 93% for calcified plaque when compared with IVUS; respectively. Misclassification occurred in 68% of mixed and 43% of noncalcified plaques. The odds of detecting noncalcified plaque in CT independently increased by 56% (95% CI: 47%-77%, P < 0.0001) with every 0.1 mm increase in maximum intimal thickness as measured by IVUS. Detection rate for noncalcified plaques was poor for plaques <1 mm (36%) but excellent for plaques >1 mm maximal intimal thickness (90%). CONCLUSION Reader agreement and diagnostic accuracy for the detection of coronary atherosclerotic plaque vary with plaque composition. Intimal thickness independently predicts detection of noncalcified plaque by CT with excellent sensitivity for >1 mm thick plaques.
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Affiliation(s)
- Alina G van der Giessen
- Cardiac MRI PET CT Program, Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02144, USA
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Performance and efficacy of 320-row computed tomography coronary angiography in patients presenting with acute chest pain: results from a clinical registry. Int J Cardiovasc Imaging 2011; 28:865-76. [PMID: 21614485 PMCID: PMC3360867 DOI: 10.1007/s10554-011-9889-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2011] [Accepted: 05/11/2011] [Indexed: 01/10/2023]
Abstract
The purpose of this study was to evaluate the performance of 320-row computed tomography angiography (CTA) in the identification of significant coronary artery disease (CAD) in patients presenting with acute chest pain and to examine the relation to outcome during follow-up. A total of 106 patients with acute chest pain underwent CTA to evaluate presence of CAD. Each CTA was classified as: normal, non-significant CAD (<50% luminal narrowing) and significant CAD (≥50% luminal narrowing). CTA results were compared with quantitative coronary angiography. After discharge, the following cardiovascular events were recorded: cardiac death, non-fatal infarction, and unstable angina requiring revascularization. Among the 106 patients, 23 patients (22%) had a normal CTA, 19 patients (18%) had non-significant CAD on CTA, 59 patients (55%) had significant CAD on CTA, and 5 patients (5%) had non-diagnostic image quality. In total, 16 patients (15%) were immediately discharged after normal CTA and 90 patients (85%) underwent invasive coronary angiography. Sensitivity, specificity, and positive and negative predictive values to detect significant CAD on CTA were 100, 87, 93, and 100%, respectively. During mean follow-up of 13.7 months, no cardiovascular events occurred in patients with a normal CTA examination. In patients with non-significant CAD on CTA, no cardiac death or myocardial infarctions occurred and only 1 patient underwent revascularization due to unstable angina. In patients presenting with acute chest pain, an excellent clinical performance for the non-invasive assessment of significant CAD was demonstrated using CTA. Importantly, normal or non-significant CAD on CTA predicted a low rate of adverse cardiovascular events and favorable outcome during follow-up.
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100
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Chow BJ, Ahmed O, Small G, Alghamdi AA, Yam Y, Chen L, Wells GA. Prognostic Value of CT Angiography in Coronary Bypass Patients. JACC Cardiovasc Imaging 2011; 4:496-502. [DOI: 10.1016/j.jcmg.2011.01.015] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2010] [Revised: 01/14/2011] [Accepted: 01/18/2011] [Indexed: 10/18/2022]
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