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Glessgen CG, Boulougouri M, Vallée JP, Noble S, Platon A, Poletti PA, Paul JF, Deux JF. Artificial intelligence-based opportunistic detection of coronary artery stenosis on aortic computed tomography angiography in emergency department patients with acute chest pain. EUROPEAN HEART JOURNAL OPEN 2023; 3:oead088. [PMID: 37744954 PMCID: PMC10516619 DOI: 10.1093/ehjopen/oead088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 08/08/2023] [Accepted: 09/06/2023] [Indexed: 09/26/2023]
Abstract
Aims To evaluate a deep-learning model (DLM) for detecting coronary stenoses in emergency room patients with acute chest pain (ACP) explored with electrocardiogram-gated aortic computed tomography angiography (CTA) to rule out aortic dissection. Methods and results This retrospective study included 217 emergency room patients (41% female, mean age 67.2 years) presenting with ACP and evaluated by aortic CTA at our institution. Computed tomography angiography was assessed by two readers, who rated the coronary arteries as 1 (no stenosis), 2 (<50% stenosis), or 3 (≥50% stenosis). Computed tomography angiography was categorized as high quality (HQ), if all three main coronary arteries were analysable and low quality (LQ) otherwise. Curvilinear coronary images were rated by a DLM using the same system. Per-patient and per-vessel analyses were conducted. One hundred and twenty-one patients had HQ and 96 LQ CTA. Sensitivity, specificity, positive predictive value, negative predictive value (NPV), and accuracy of the DLM in patients with high-quality image for detecting ≥50% stenoses were 100, 62, 59, 100, and 75% at the patient level and 98, 79, 57, 99, and 84% at the vessel level, respectively. Sensitivity was lower (79%) for detecting ≥50% stenoses at the vessel level in patients with low-quality image. Diagnostic accuracy was 84% in both groups. All 12 patients with acute coronary syndrome (ACS) and stenoses by invasive coronary angiography (ICA) were rated 3 by the DLM. Conclusion A DLM demonstrated high NPV for significant coronary artery stenosis in patients with ACP. All patients with ACS and stenoses by ICA were identified by the DLM.
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Affiliation(s)
- Carl G Glessgen
- Department of Radiology, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, Geneva 1205, Switzerland
| | - Marianthi Boulougouri
- Department of Radiology, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, Geneva 1205, Switzerland
| | - Jean-Paul Vallée
- Department of Radiology, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, Geneva 1205, Switzerland
| | - Stéphane Noble
- Department of Cardiology, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, Geneva 1205, Switzerland
| | - Alexandra Platon
- Department of Radiology, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, Geneva 1205, Switzerland
| | - Pierre-Alexandre Poletti
- Department of Radiology, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, Geneva 1205, Switzerland
| | - Jean-François Paul
- Department of Radiology, Cardiac Imaging, Institut Mutualiste Montsouris, Paris 75014, France
| | - Jean-François Deux
- Department of Radiology, Geneva University Hospitals, Rue Gabrielle-Perret-Gentil 4, Geneva 1205, Switzerland
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2
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Koh N, Nieman K. Role of cardiac imaging in acute chest pain. Br J Radiol 2023; 96:20220307. [PMID: 36533544 PMCID: PMC9975370 DOI: 10.1259/bjr.20220307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 11/04/2022] [Accepted: 11/18/2022] [Indexed: 12/23/2022] Open
Abstract
Chest pain is the second most common complaint in the emergency department. The need to diagnose the cause of chest pain in a timely manner and appropriately direct care is crucial. This article discusses the role of imaging in acute chest pain, after first differentiating chest pain into cardiac and non-cardiac causes with upfront clinical and biochemical assessment. The role of non-invasive imaging including point-of-care ultrasound, echocardiography, myocardial perfusion imaging, cardiac MRI, coronary computed tomography angiography and novel cardiac CT applications are discussed. Updates in the literature regarding the role of coronary plaque imaging in acute chest pain are reviewed, as are ongoing challenges and future directions. This includes a discussion on the yield of diagnostic testing in low-risk acute chest pain cohorts vs intermediate-high risk cohorts. The incremental value of further testing in the former is low, which is reflected in contemporary guidelines that discourage the use of costly diagnostic tests in these cohorts. In the latter cohort, emerging evidence has shown specifically the role coronary computed tomography angiography could play in reducing the need for invasive coronary angiography in selective patients where the true probability of acute coronary syndrome is thought to be low. Real-world considerations such as accessibility and affordability are also discussed in the paper because while guidelines offer clinicians the flexibility of evidence-based choice, physician decision must necessarily be made in consideration of real-world constraints.
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Affiliation(s)
- Natalie Koh
- Department of Cardiology, National Heart Centre Singapore, Singapore, Singapore
| | - Koen Nieman
- Departments of Cardiovascular Medicine and Radiology, Stanford University, School of Medicine, Stanford, CA, USA
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3
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Mehta P, McDonald S, Hirani R, Good D, Diercks D. Major adverse cardiac events after emergency department evaluation of chest pain patients with advanced testing: Systematic review and meta-analysis. Acad Emerg Med 2022; 29:748-764. [PMID: 34741781 DOI: 10.1111/acem.14407] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 10/15/2021] [Accepted: 10/26/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Our primary objective was to describe the risk of major adverse cardiac events (MACE) at 1, 6, and 12 months after a negative coronary computed tomography angiogram (cCTA), electrocardiogram (ECG) stress test, stress echocardiography, and myocardial perfusion scintigraphy (MPS) in low- to intermediate-risk patients. METHODS Initially, 952 articles were identified for screening, 81 met criteria for full-text review, and once risk of bias was assessed, 33 articles were included in this meta-analysis. We utilized a random-effects model to assess pooled MACE event proportion for patients undergoing evaluation of acute coronary syndrome (ACS) when risk stratified to a low- to intermediate-risk category after undergoing standard testing. Heterogeneity analysis was performed using Cochrane's Q-test and I2 statistic. RESULTS Twenty-one studies evaluated follow-up at 1 month with cCTA having a 0.09% (95% confidence interval [CI] = 0.03% to 0.26%) pooled MACE compared to 0.23% (95% CI = 0.01% to 5.8%) of the exercise stress testing (p = 1). MPS and cCTA had an overall event rate of 0.15% (95% CI = 0.06% to 0.41%) at 6 months (I2 = 0%). At 12 months, a subgroup analysis found a pooled cCTA MACE of 0.16% (95% CI = 0.04% to 0.65%) compared to 1.68% (95% CI = 0.01% to 2.6%) for stress echocardiography with low within-group heterogeneity (I2 = 0%). Subgroup analysis of cCTA with no disease versus nonobstructive disease (<50% stenosis) did not find statistical difference in the MACE at both 1 month (0.17% [95% CI = 0.04% to 0.67%] vs. 0.06% [95% CI = 0.01% to 0.34%]) and 12 months (0.44% [95% CI = 0.09% to 2.2% vs. 0.54% [95% CI = 0.19% to 1.5%]). CONCLUSIONS Patients presenting with chest pain who have a coronary CTA showing < 50% stenosis, negative ECG stress test, stress echocardiography, or stress myocardial perfusion scan in the past 12 months can be discharged without any further risk stratification if their ECG and troponin are reassuring given low MACE.
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Affiliation(s)
- Prayag Mehta
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Samuel McDonald
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Clinical Informatics Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Raiz Hirani
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Daniel Good
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Deborah Diercks
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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4
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Pontone G, Rossi A, Guglielmo M, Dweck MR, Gaemperli O, Nieman K, Pugliese F, Maurovich-Horvat P, Gimelli A, Cosyns B, Achenbach S. Clinical applications of cardiac computed tomography: a consensus paper of the European Association of Cardiovascular Imaging-part I. Eur Heart J Cardiovasc Imaging 2022; 23:299-314. [PMID: 35076061 PMCID: PMC8863074 DOI: 10.1093/ehjci/jeab293] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 12/14/2021] [Indexed: 01/26/2023] Open
Abstract
Cardiac computed tomography (CT) was introduced in the late 1990's. Since then, an increasing body of evidence on its clinical applications has rapidly emerged. From an initial emphasis on its technical efficiency and diagnostic accuracy, research around cardiac CT has now evolved towards outcomes-based studies that provide information on prognosis, safety, and cost. Thanks to the strong and compelling data generated by large, randomized control trials, the scientific societies have endorsed cardiac CT as pivotal diagnostic test for the management of appropriately selected patients with acute and chronic coronary syndrome. This consensus document endorsed by the European Association of Cardiovascular Imaging is divided into two parts and aims to provide a summary of the current evidence and to give updated indications on the appropriate use of cardiac CT in different clinical scenarios. This first part focuses on the most established applications of cardiac CT from primary prevention in asymptomatic patients, to the evaluation of patients with chronic coronary syndrome, acute chest pain, and previous coronary revascularization.
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Affiliation(s)
- Gianluca Pontone
- Centro Cardiologico Monzino IRCCS, Via C. Parea 4, 20138 Milan, Italy
| | - Alexia Rossi
- Department of Nuclear Medicine, University Hospital, Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Marco Guglielmo
- Centro Cardiologico Monzino IRCCS, Via C. Parea 4, 20138 Milan, Italy
| | - Marc R Dweck
- Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK
| | | | - Koen Nieman
- Department of Radiology and Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Francesca Pugliese
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, UK
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Pal Maurovich-Horvat
- MTA-SE Cardiovascular Imaging Research Group, Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Alessia Gimelli
- Fondazione CNR/Regione Toscana “Gabriele Monasterio”, Pisa, Italy
| | - Bernard Cosyns
- Department of Cardiology, CHVZ (Centrum voor Hart en Vaatziekten), ICMI (In Vivo Cellular and Molecular Imaging) Laboratory, Universitair ziekenhuis Brussel, Brussel, Belgium
| | - Stephan Achenbach
- Department of Cardiology, Friedrich-Alexander-University of Erlangen, Erlangen, Germany
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5
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Arslan M, Schaap J, Van Gorsel B, Budde RP, Bekkers SC, Van Cauteren YJ, Damman P, Habets J, Dubois EA, Dedic A. Coronary CT angiography for improved assessment of patients with acute chest pain and low-range positive high-sensitivity troponins: study protocol for a prospective, observational, multicentre study (COURSE trial). BMJ Open 2021; 11:e049349. [PMID: 34663657 PMCID: PMC8524275 DOI: 10.1136/bmjopen-2021-049349] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Current evaluation of patients suspected of a non-ST-elevation acute coronary syndrome (NSTE-ACS) involves the use of algorithms that incorporate clinical information, electrocardiogram (ECG) and high-sensitivity cardiac troponins (hs-troponins). While primarily designed to rule out NSTE-ACS safely, these algorithms can also be used for rule in of NSTE-ACS in some patients. Still, in a substantial number of patients, these algorithms do not provide a conclusive work-up. These patients often present with an atypical clinical profile and low-range positive hs-troponin values without a characteristic rise or fall pattern. They represent a heterogeneous group of patients with various underlying conditions; only a fraction (30%-40%) will eventually be diagnosed with a myocardial infarction. Uncertainty exists about the optimal diagnostic strategy and their management depends on the clinical perspective of the treating physician ranging from direct discharge to admission for invasive coronary angiography. Coronary CT angiography (CCTA) is a non-invasive test that has been shown to be safe, fast and reliable in the evaluation of coronary artery disease. In this study, we will determine the usefulness of CCTA in patients with acute chest pain and low-range positive hs-troponin values. METHODS AND ANALYSIS A prospective, double-blind, observational, multicentre study conducted in the Netherlands. Patients aged 30-80 years presenting to the emergency department with acute chest pain and a suspicion of NSTE-ACS, a normal or non-diagnostic ECG and low-range positive hs-troponins will be scheduled to undergo CCTA. The primary outcome is the diagnostic accuracy of CCTA for the diagnosis of NSTE-ACS at discharge, in terms of sensitivity and negative predictive value. ETHICS AND DISSEMINATION This study was approved by the Medical Research Ethics Committee of Erasmus Medical Center in Rotterdam, the Netherlands (registration number MEC-2017-506). Written informed consent to participate will be obtained from all participants. This study's findings will be published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER ClinicalTrials.gov (NCT03129659).
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Affiliation(s)
- Murat Arslan
- Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
- Radiology and Nuclear Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | | | - Ricardo Pj Budde
- Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
- Radiology and Nuclear Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | | | | | - Peter Damman
- Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jesse Habets
- Radiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Eric A Dubois
- Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
- Intensive Care, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Admir Dedic
- Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
- Radiology and Nuclear Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
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6
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Coronary CT Angiography Guided Medical Therapy in Subclinical Atherosclerosis. J Clin Med 2021; 10:jcm10040625. [PMID: 33562179 PMCID: PMC7914610 DOI: 10.3390/jcm10040625] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 01/31/2021] [Accepted: 02/01/2021] [Indexed: 12/11/2022] Open
Abstract
The goals of primary prevention in coronary atherosclerosis are to avoid sudden cardiac death, myocardial infarction or the need for revascularization procedures. Successful prevention will rely on accurate identification, effective therapy and monitoring of those at risk. Identification and potential monitoring can be achieved using cardiac computed tomography (CT). Cardiac CT can determine coronary artery calcification (CAC), a useful surrogate of coronary atherosclerosis burden. Cardiac CT can also assess coronary CT angiography (CCTA). CCTA can identify arterial lumen narrowing and highlight mural atherosclerosis hitherto hidden from other anatomical approaches. Herein we consider the role of CCTA and CAC-scoring in subclinical atherosclerosis. We explore the use of these modalities in screening and discuss data that has used CCTA for guiding primary prevention. We examine therapeutic trials using CCTA to determine the effects of plaque-modifying therapies. Finally, we address the role of CCTA and CAC to guide therapy as defined in current primary prevention documents. CCTA has emerged as an essential tool in the detection and management of clinical coronary artery disease. To date, its role in subclinical atherosclerosis is less well defined, yet with modern CT scanners and continued pharmacotherapy development, CCTA is likely to achieve a more prominent place in the primary prevention of coronary atherosclerosis.
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7
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Arslan M, Schaap J, Rood PP, Nieman K, Budde RP, Attrach M, Dubois EA, Dedic A. HEART score improves efficiency of coronary computed tomography angiography in patients suspected of acute coronary syndrome in the emergency department. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2019; 9:23-29. [PMID: 31647305 PMCID: PMC7008554 DOI: 10.1177/2048872619882424] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Aims: Coronary computed tomography angiography is increasingly employed in the emergency department for suspected acute coronary syndrome patients. The HEART score has been proposed for initial risk stratification in these patients. The aim of this study was to investigate the diagnostic value and efficiency of the HEART score before coronary computed tomography angiography. Methods and results: We included patients suspected of acute coronary syndrome who underwent coronary computed tomography angiography in the emergency department. Based on the HEART score, patients were stratified as low-risk (HEART≤3), intermediate-risk (HEART4–6) and high-risk (HEART≥7). We assessed coronary computed tomography angiography for the presence of significant coronary artery disease (>50% stenosis). The primary outcome, the level of major adverse cardiac events, was a composite endpoint of all-cause mortality, acute coronary syndrome or coronary revascularisation within 30 days. The study population consisted of 340 patients (mean age: 55.6±10.1 years, 44.7% women), major adverse cardiac events occurred in 45 (13.2%) patients. The incidence of major adverse cardiac events in patients stratified as low-risk (35.0%), intermediate-risk (56.8%) and high-risk (8.2%) was 3.4%, 12.4% and 60.7%, respectively. All four low-risk patients with major adverse cardiac events had a HEART score of three. An algorithm where coronary computed tomography angiography is reserved for patients with HEART 3–6 resulted in a sensitivity of 97.8%, specificity of 84.1%, negative predictive value of 99.6% and positive predictive value of 48.4%, while reducing the need for coronary computed tomography angiography by 22% (n=75). Conclusion: The predictive value of coronary computed tomography angiography for 30-day major adverse cardiac events in suspected acute coronary syndrome patients is good, and reserving coronary computed tomography angiography for HEART score 3–6 patients reduces the number of needed coronary computed tomography angiograms without affecting diagnostic accuracy.
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Affiliation(s)
- Murat Arslan
- Department of Cardiology, Erasmus Medical Centre, The Netherlands.,Department of Radiology and Nuclear Medicine, Erasmus Medical Centre, The Netherlands
| | - Jeroen Schaap
- Department of Cardiology, Amphia Ziekenhuis, The Netherlands
| | - Pleunie Pm Rood
- Department of Emergency Medicine, Erasmus Medical Centre, The Netherlands
| | - Koen Nieman
- Department of Cardiology, Erasmus Medical Centre, The Netherlands.,Department of Radiology and Nuclear Medicine, Erasmus Medical Centre, The Netherlands
| | - Ricardo Pj Budde
- Department of Cardiology, Erasmus Medical Centre, The Netherlands.,Department of Radiology and Nuclear Medicine, Erasmus Medical Centre, The Netherlands
| | - Mohamed Attrach
- Department of Radiology and Nuclear Medicine, Erasmus Medical Centre, The Netherlands
| | - Eric A Dubois
- Department of Cardiology, Erasmus Medical Centre, The Netherlands
| | - Admir Dedic
- Department of Cardiology, Erasmus Medical Centre, The Netherlands.,Department of Radiology and Nuclear Medicine, Erasmus Medical Centre, The Netherlands
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8
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The role of coronary CT angiography for acute chest pain in the era of high-sensitivity troponins. J Cardiovasc Comput Tomogr 2019; 13:267-273. [PMID: 31235403 DOI: 10.1016/j.jcct.2019.05.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 05/01/2019] [Accepted: 05/02/2019] [Indexed: 11/22/2022]
Abstract
Accurate and efficient diagnostic triage for acute chest pain (ACP) remains one of the most challenging problems in the emergency department (ED). While the proportion of patients that present with myocardial infarction (MI), aortic dissection, or pulmonary embolism is relatively low, a missed diagnosis can be life threatening. Coronary computed tomography angiography (CCTA) has developed into a robust diagnostic tool in the triage of ACP over the past decade, with several trials showing that it can reliably identify patients at low risk of major adverse cardiovascular events, shorten the length of stay in the ED, and reduce cost associated with the triage of patients with undifferentiated chest pain. Recently, however, high-sensitivity troponin assays have been increasingly incorporated as a rapid and efficient diagnostic test in the triage of ACP due to their higher sensitivity and negative predictive value of myocardial infarction. As more EDs adopt high-sensitivity troponin assays into routine clinical practice, the role of CCTA will likely change. In this review, we provide an overview of CCTA and high-sensitivity troponins for evaluation of patients with suspected ACS in the ED. Moreover, we discuss the changing role of CCTA in the era of high-sensitivity troponins.
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9
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Koopmann M, Hinrichs L, Olligs J, Lichtenberg M, Eckardt L, Böse D, Möhlenkamp S, Waltenberger J, Breuckmann F. Cardiac computed tomography in patients with symptomatic new-onset atrial fibrillation, rule-out acute coronary syndrome, but with intermediate pretest probability for coronary artery disease admitted to a chest pain unit. Eur J Med Res 2018; 23:6. [PMID: 29361983 PMCID: PMC5782369 DOI: 10.1186/s40001-018-0303-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 01/17/2018] [Indexed: 12/14/2022] Open
Abstract
Background Atrial fibrillation (AF) and coronary artery disease (CAD) may be encountered coincidently in a large portion of patients. However, data on coronary artery calcium burden in such patients are lacking. Thus, we sought to determine the value of cardiac computed tomography (CCT) in patients presenting with new-onset AF associated with an intermediate pretest probability for CAD admitted to a chest pain unit (CPU). Methods Calcium scores (CS) of 73 new-onset, symptomatic AF subjects without typical clinical, electrocardiographic, or laboratory signs of acute coronary syndrome (ACS) admitted to our CPU were analyzed. In addition, results from computed tomography angiography (CTA) were related to coronary angiography findings whenever available. Results Calcium scores of zero were found in 25%. Median Agatston score was 77 (interquartile range: 1–270) with gender- and territory-specific dispersal. CS scores above average were present in about 50%, high (> 400)-to-very high (> 1000) CS scores were found in 22%. Overall percentile ranking showed a relative accordance to the reference percentile distribution. Additional CTA was performed in 47%, revealing stenoses in 12%. Coronary angiography was performed in 22% and resulted in coronary intervention or surgical revascularization in 7%. On univariate analysis, CS > 50th percentile failed to serve as an independent determinant of significant stenosis during catheterization. Conclusions Within a CPU setting, relevant CAD was excluded or confirmed in almost 50%, the latter with a high proportion of coronary angiographies and subsequent coronary interventions, underlining the diagnostic value of CCT in symptomatic, non-ACS, new-onset AF patients when admitted to a CPU.
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Affiliation(s)
- Matthias Koopmann
- Division of Electrophysiology, Department of Cardiovascular Medicine, University of Münster, Münster, Germany
| | - Liane Hinrichs
- Department of Anesthesiology, Arnsberg Medical Center, Arnsberg, Germany
| | - Jan Olligs
- Division of Electrophysiology, Department of Cardiovascular Medicine, University of Münster, Münster, Germany
| | | | - Lars Eckardt
- Division of Electrophysiology, Department of Cardiovascular Medicine, University of Münster, Münster, Germany
| | - Dirk Böse
- Department of Cardiology, Arnsberg Medical Center, Stolte Ley 5, 59759, Arnsberg, Germany
| | - Stefan Möhlenkamp
- Clinic of Cardiology and Intensive Care Medicine, Bethanien Hospital Moers, Moers, Germany
| | | | - Frank Breuckmann
- Department of Cardiology, Arnsberg Medical Center, Stolte Ley 5, 59759, Arnsberg, Germany.
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10
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Abstract
OBJECTIVE The German Cardiac Society runs a nation-wide certification campaign for specialized chest pain units (CPUs). So far, cardiac computed tomography (CT) is not an integral part of such certification. The aim of our study was to analyze whether or not cardiac CT is nevertheless routinely used for further stratification in low-risk patients. METHODS For the time interval from January 2010 to April 2011, data were retrieved from the mandatory German CPU registry. Patients with and without cardiac CT during CPU index stay were compared. RESULTS Out of 5800 patients, 314 patients (5.4%) underwent cardiac CT during the index CPU stay. Unstable angina pectoris was the most common diagnosis when performing cardiac CT [34.4% vs. 17.7%; odds ratio (OR), 2.44; confidence interval (CI), 1.91-3.11; P < 0.001). Patients undergoing cardiac CT received significantly less often coronary angiography (31.8% vs. 54.8%; OR, 0.39; CI, 0.30-0.49; P < 0.001) or coronary revascularization (15.6% vs. 36.5%; OR, 0.32; CI, 0.23-0.46; P < 0.001). The use of cardiac CT did not prolong the length of stay in the CPU (20:48 vs. 20:25 h, P = 0.21). CONCLUSIONS Cardiac CT is underrepresented within the diagnostic work up in certified CPUs in Germany, although its use reduces unnecessary invasive diagnostics. The use of cardiac CT should be reconsidered during the next update of the CPU certification criteria.
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11
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Chen K, Schneider ALC, Llinas RH, Marsh EB. Keep it simple: vascular risk factors and focal exam findings correctly identify posterior circulation ischemia in "dizzy" patients. BMC Emerg Med 2016; 16:37. [PMID: 27619651 PMCID: PMC5020437 DOI: 10.1186/s12873-016-0101-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 09/08/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Dizziness is a common chief complaint of patients presenting to the Emergency Department (ED). Physicians must quickly and accurately identify patients whose etiology is most likely ischemia. Additional tools are available, but often require further training (vestibular testing) or are costly and not always readily available (magnetic resonance imaging (MRI)). This study evaluates the ability of a routine history and simple physical examination to correctly identify dizzy patients with posterior circulation ischemia, and the added utility of CT angiography (CTA). METHODS We performed a retrospective analysis of all individuals presenting to the ED with a reported chief complaint of dizziness. Neurology was consulted and CTA ordered at the discretion of the ED provider. Demographic, medical, and radiographic variables were evaluated along with final diagnosis. Multivariable logistic regression and ROC analysis were used to determine factors associated with ischemia, the sensitivity of vascular risk factors and focal exam findings in predicting ischemia, and the additional benefit, if any, of CTA. RESULTS One thousand two-hundred sixteen individuals meeting inclusion criteria presented to the ED over a 2 year period and were included in analysis. One hundred (8.2 %) were diagnosed with posterior circulation ischemia. For the entire cohort, age (OR 1.4 per 10 years, p < 0.0001), systolic blood pressure (OR 1.3 per 10 mmHg, p < 0.0001), and focal exam findings (OR 28.69, p < 0.0001) were most significantly associated with ischemia in multivariable modeling. When age, race, sex, presence of vascular risk factors, and focal neurologic findings were entered into ROC analysis, the AUC for correctly identifying posterior circulation ischemia was 0.90. In the subset of patients who underwent CTA (n = 87), the AUC did not improve (0.78 with and without CTA in ROC analysis, p = 0.52). CONCLUSIONS A vascular risk assessment and neurological examination are adequate for risk stratification of ischemia in the dizzy patient and should remain the standard evaluation.
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Affiliation(s)
- Karen Chen
- The Johns Hopkins University School of Medicine, 600 North Wolfe St. Phipps 446C, Baltimore, 21287, MD, USA
| | - Andrea L C Schneider
- The Johns Hopkins University School of Medicine, 600 North Wolfe St. Phipps 446C, Baltimore, 21287, MD, USA
| | - Rafael H Llinas
- The Johns Hopkins University School of Medicine, 600 North Wolfe St. Phipps 446C, Baltimore, 21287, MD, USA
| | - Elisabeth B Marsh
- The Johns Hopkins University School of Medicine, 600 North Wolfe St. Phipps 446C, Baltimore, 21287, MD, USA.
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12
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Smulders MW, Kietselaer BL, Schalla S, Bucerius J, Jaarsma C, van Dieijen-Visser MP, Mingels AM, Rocca HPBL, Post M, Das M, Crijns HJ, Wildberger JE, Bekkers SC. Acute chest pain in the high-sensitivity cardiac troponin era: A changing role for noninvasive imaging? Am Heart J 2016; 177:102-11. [PMID: 27297855 DOI: 10.1016/j.ahj.2016.03.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 03/30/2016] [Indexed: 02/07/2023]
Abstract
Management of patients with acute chest pain remains challenging. Cardiac biomarker testing reduces the likelihood of erroneously discharging patients with acute myocardial infarction (AMI). Despite normal contemporary troponins, physicians have still been reluctant to discharge patients without additional testing. Nowadays, the extremely high negative predictive value of current high-sensitivity cardiac troponin (hs-cTn) assays challenges this need. However, the decreased specificity of hs-cTn assays to diagnose AMI poses a new problem as noncoronary diseases (eg, pulmonary embolism, myocarditis, cardiomyopathies, hypertension, renal failure, etc) may also cause elevated hs-cTn levels. Subjecting patients with noncoronary diseases to unnecessary pharmacological therapy or invasive procedures must be prevented. Attempts to improve the positive predictive value to diagnose AMI by defining higher initial cutoff values or dynamic changes over time inherently lower the sensitivity of troponin assays. In this review, we anticipate a potential changing role of noninvasive imaging from ruling out myocardial disease when troponin values are normal toward characterizing myocardial disease when hs-cTn values are (mildly) abnormal.
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Maffei E, Seitun S, Guaricci AI, Cademartiri F. Chest pain: coronary CT in the ER. Br J Radiol 2016; 89:20150954. [PMID: 26866681 PMCID: PMC4985473 DOI: 10.1259/bjr.20150954] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 01/14/2016] [Accepted: 01/20/2016] [Indexed: 01/16/2023] Open
Abstract
Cardiac CT has developed into a robust clinical tool during the past 15 years. Of the fields in which the potential of cardiac CT has raised more interest is chest pain in acute settings. In fact, the possibility to exclude with high reliability obstructive coronary artery disease (CAD) in patients at low-to-intermediate risk is of great interest both from the clinical standpoint and from the management standpoint. Several other modalities, with or without imaging, have been used during the past decades in the settings of new onset chest pain or in acute chest pain for both diagnostic and prognostic assessment of CAD. Each one has advantages and disadvantages. Most imaging modalities also focus on inducible ischaemia to guide referral to invasive coronary angiography. The advent of cardiac CT has introduced a new practice diagnostic paradigm, being the most accurate non-invasive method for identification and exclusion of CAD. Furthermore, the detection of subclinical CAD and plaque imaging offer the opportunity to improve risk stratification. Moreover, recent advances of the latest generation CT scanners allow combining both anatomical and functional imaging by stress myocardial perfusion. The role of cardiac CT in acute settings is already important and will become progressively more important in the coming years.
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Affiliation(s)
- Erica Maffei
- Centre de Recherché/Department of Radiology, Montréal Heart Institute/Universitè de Montréal, Montréal, Quebec, Canada
| | - Sara Seitun
- Department of Radiology, IRCCS San Martino University Hospital—IST, Genoa, Italy
| | | | - Filippo Cademartiri
- Centre de Recherché/Department of Radiology, Montréal Heart Institute/Universitè de Montréal, Montréal, Quebec, Canada
- Department of Radiology, Erasmus Medical Center University, Rotterdam, Netherlands
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14
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Coronary CT Angiography for Suspected ACS in the Era of High-Sensitivity Troponins. J Am Coll Cardiol 2016; 67:16-26. [DOI: 10.1016/j.jacc.2015.10.045] [Citation(s) in RCA: 108] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2015] [Revised: 08/26/2015] [Accepted: 10/20/2015] [Indexed: 02/07/2023]
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15
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Nieman K, Coenen A. Myocardial Enhancement Defects on CT Angiograms: Promising Prognosticator or Water Under the Bridge? JACC Cardiovasc Imaging 2015; 8:695-6. [PMID: 26068286 DOI: 10.1016/j.jcmg.2015.02.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 02/17/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Koen Nieman
- Departments of Cardiology and Radiology, Erasmus Medical Center, Rotterdam, the Netherlands.
| | - Adriaan Coenen
- Departments of Cardiology and Radiology, Erasmus Medical Center, Rotterdam, the Netherlands
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Abstract
Hypertension affects approximately one-third of Americans. An additional 30% are unaware that they harbor the disease. Significantly increased blood pressure constitutes a hypertensive emergency that could lead to end-organ damage. When organs such as the brain, heart, or kidney are affected, an intervention that will lower the blood pressure in several hours is indicated. Several pharmacologic options are available for treatment, with intravenous antihypertensive therapy being the cornerstone, but there is no standard of care. Careful consideration of each patient's specific complaint, history, and physical examination guides the emergency physician through the treatment algorithm.
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Affiliation(s)
- Omoyemi Adebayo
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
| | - Robert L Rogers
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA
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17
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Updates on Coronary CTA in the Emergency Department. CURRENT RADIOLOGY REPORTS 2015. [DOI: 10.1007/s40134-015-0096-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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18
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An online tool for nurse triage to evaluate risk for acute coronary syndrome at emergency department. Emerg Med Int 2015; 2015:413047. [PMID: 25922767 PMCID: PMC4398917 DOI: 10.1155/2015/413047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2014] [Revised: 03/19/2015] [Accepted: 03/20/2015] [Indexed: 12/04/2022] Open
Abstract
Background. To differentiate acute coronary syndrome (ACS)
from other causes in patients presenting with chest pain at the emergency department
(ED) is crucial and can be performed by the nurse triage. We evaluated the effectiveness
of the ED nurse triage for ACS of the tertiary care hospital. Methods. We retrospectively
enrolled consecutive patients who were identified as ACS at risk patients by the ED nurse triage.
Patients were categorized as ACS and non-ACS group by the final diagnosis.
Multivariate logistic analysis was used to predict factors associated with ACS.
An online model predictive of ACS for the ED nurse triage was constructed. Results. There were
175 patients who met the study criteria. Of those, 28 patients (16.0%) were diagnosed with ACS.
Patients with diabetes, patients with previous history of CAD, and those who had at least one character
of ACS chest pain were independently associated with having ACS by multivariate logistic regression. The adjusted odds ratios
(95% confidence interval) were 4.220 (1.445, 12.327), 3.333 (1.040, 10.684), and 12.539 (3.876, 40.567), respectively.
Conclusions. The effectiveness of the ED nurse triage for ACS was 16%. The online tool is available for the ED triage nurse to evaluate risk of ACS in individuals.
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Nieman K, Hoffmann U. Cardiac computed tomography in patients with acute chest pain. Eur Heart J 2015; 36:906-14. [PMID: 25687351 DOI: 10.1093/eurheartj/ehv034] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Accepted: 01/21/2015] [Indexed: 11/14/2022] Open
Abstract
The efficient and reliable evaluation of patients with acute chest pain is one of the most challenging tasks in the emergency department. Coronary computed tomography (CT) angiography may play a major role, since it permits ruling out coronary artery disease with high accuracy if performed with expertise in properly selected and prepared patients. Several randomized trials have established early cardiac CT as a viable safe and potentially more efficient alternative to functional testing in the evaluation of acute chest pain. Ongoing investigations explore whether advanced anatomic and functional assessments such as high-risk coronary plaque, resting myocardial perfusion, and left ventricular function, or the simulation of the fractional coronary flow reserve will add information to the anatomic assessment for stenosis, which would allow expanding the benefits of cardiac CT from triage to treatment decisions. Especially, the combination of high-sensitive troponins and coronary computed tomography angiography may play a valuable role in future strategies for the management of patients presenting with acute chest pain.
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Affiliation(s)
- Koen Nieman
- Erasmus MC, Department of Cardiology, Room Hs207, PO Box 2040, Rotterdam 3000 CA, The Netherlands Erasmus MC, Department Radiology, Rotterdam 3000 CA, The Netherlands
| | - Udo Hoffmann
- Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA 02114, USA
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20
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Accuracy of multidetector computed tomography for detection of coronary artery stenosis in acute coronary syndrome compared with stable coronary disease: a CORE64 multicenter trial substudy. Int J Cardiol 2014; 177:385-91. [PMID: 25281436 DOI: 10.1016/j.ijcard.2014.08.130] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 08/04/2014] [Accepted: 08/21/2014] [Indexed: 11/20/2022]
Abstract
BACKGROUND Multi-detector computed tomography angiography (MDCTA) is a promising method for risk assessment of patients with acute chest pain. However, its diagnostic performance in higher-risk patients has not been investigated in a large international multicenter trial. Therefore, in the present study we sought to estimate the diagnostic accuracy of MDCTA to detect significant coronary stenosis in patients with acute coronary syndrome (ACS). METHODS Patients included in the CORE64 study were categorized as suspected-ACS or non-ACS based on clinical data. A 64-row coronary MDCTA was performed before invasive coronary angiography (ICA) and both exams were evaluated by blinded, independent core laboratories. RESULTS From 371 patients included, 94 were categorized as suspected ACS and 277 as non-ACS. Patient-based analysis showed an area under the receiver-operating-characteristic curve (AUC) for detecting ≥ 50% coronary stenosis of 0.95 (95% CI: 0.88-0.98) in ACS and 0.92 (95% CI: 0.88-0.95) in non-ACS group (P=0.29). The sensitivity, specificity, positive and negative predictive values of MDCTA were 0.90(0.80-0.96), 0.88(0.70-0.98), 0.95(0.87-0.99) and 0.77(0.58-0.90) in suspected ACS patients and 0.87(0.81-0.92), 0.86(0.79-0.92), 0.91(0.85-0.95) and 0.82(0.74-0.89) in non-ACS patients (P NS for all comparisons). The mean calcium scores (CS) were 282 ± 449 in suspected ACS and 435 ± 668 in non-ACS group. The accuracy of CS to detect significant coronary stenosis was only moderate and the absence or minimal coronary artery calcification could not exclude the presence of significant coronary stenosis, particularly in ACS patients. CONCLUSIONS The diagnostic accuracy of MDCTA to detect significant coronary stenosis is high and comparable for both ACS and non-ACS patients.
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Dedic A, Kurata A, Lubbers M, Meijboom WB, van Dalen BM, van Dalen B, Snelder S, Korbee R, Moelker A, Ouhlous M, van Domburg R, de Feijter PJ, Nieman K. Prognostic implications of non-culprit plaques in acute coronary syndrome: non-invasive assessment with coronary CT angiography. Eur Heart J Cardiovasc Imaging 2014; 15:1231-7. [PMID: 24939941 DOI: 10.1093/ehjci/jeu111] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
AIMS Non-culprit plaques are responsible for a substantial number of future events in patients with acute coronary syndrome (ACS). In this study, we evaluated the prognostic implications of non-culprit plaques seen on coronary computed tomography angiography (CTA) in patients with ACS. METHODS AND RESULTS Coronary CTA was performed in 169 patients (mean 59 ± 11 years, 129 males) admitted with ACS. Data sets were assessed for the presence of obstructive non-culprit plaques (>50% luminal narrowing), segment involvement score, and quantitative measures of plaque burden, after censoring initial culprit plaques. Follow-up was performed for the occurrence of major adverse cardiovascular events (MACEs) unrelated to the initial culprit plaque; cardiac death, second ACS, or coronary revascularization after 90 days. After a median follow-up of 4.8 (IQR 2.6-6.6) years, MACE occurred in 36 (24%) patients: 6 cardiac deaths, 16 second ACS, and 14 coronary revascularizations. Dyslipidaemia (hazard ratio [HR] 3.1 [95% confidence interval 1.5-6.6]) and diabetes mellitus (HR 4.8 [2.3-10.3]) were univariable clinical predictors of MACE. Patients with remaining obstructive non-culprit plaques (HR 3.66 [1.52-8.80]) and higher plaque burden index (HR 1.22 [1.01-1.48]) had a more risk of MACE. In multivariate analysis, with diabetes, dyslipidaemia, and plaque burden index, obstructive non-culprit plaques (HR 3.76 [1.28-11.09]) remained an independent predictor of MACE. CONCLUSION Almost a quarter of the study population experienced a new event arising from a non-culprit plaque during a follow-up of almost 5 years. ACS patients with remaining obstructive non-culprit plaques or high plaque burden have an increased risk of future MACE.
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Affiliation(s)
- Admir Dedic
- Department of Cardiology, Erasmus Medical Centre, Rotterdam, The Netherlands Department of Radiology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Akira Kurata
- Department of Radiology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Marisa Lubbers
- Department of Cardiology, Erasmus Medical Centre, Rotterdam, The Netherlands Department of Radiology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Willem Bob Meijboom
- Department of Cardiology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | | | - Bas van Dalen
- Department of Cardiology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Sanne Snelder
- Department of Cardiology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Rebbeca Korbee
- Department of Cardiology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Adriaan Moelker
- Department of Radiology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Mohamed Ouhlous
- Department of Radiology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Ron van Domburg
- Department of Cardiology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Pim J de Feijter
- Department of Cardiology, Erasmus Medical Centre, Rotterdam, The Netherlands Department of Radiology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Koen Nieman
- Department of Cardiology, Erasmus Medical Centre, Rotterdam, The Netherlands Department of Radiology, Erasmus Medical Centre, Rotterdam, The Netherlands
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