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Ayoub C, Scalia IG, Anavekar NS, Arsanjani R, Jokerst CE, Chow BJW, Kritharides L. Computed Tomography Evaluation of Coronary Atherosclerosis: The Road Travelled, and What Lies Ahead. Diagnostics (Basel) 2024; 14:2096. [PMID: 39335775 PMCID: PMC11431535 DOI: 10.3390/diagnostics14182096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2024] [Revised: 09/18/2024] [Accepted: 09/19/2024] [Indexed: 09/30/2024] Open
Abstract
Coronary CT angiography (CCTA) is now endorsed by all major cardiology guidelines for the investigation of chest pain and assessment for coronary artery disease (CAD) in appropriately selected patients. CAD is a leading cause of morbidity and mortality. There is extensive literature to support CCTA diagnostic and prognostic value both for stable and acute symptoms. It enables rapid and cost-effective rule-out of CAD, and permits quantification and characterization of coronary plaque and associated significance. In this comprehensive review, we detail the road traveled as CCTA evolved to include quantitative assessment of plaque stenosis and extent, characterization of plaque characteristics including high-risk features, functional assessment including fractional flow reserve-CT (FFR-CT), and CT perfusion techniques. The state of current guideline recommendations and clinical applications are reviewed, as well as future directions in the rapidly advancing field of CT technology, including photon counting and applications of artificial intelligence (AI).
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Affiliation(s)
- Chadi Ayoub
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Isabel G Scalia
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Nandan S Anavekar
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Reza Arsanjani
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
| | | | - Benjamin J W Chow
- Department of Medicine (Cardiology), University of Ottawa Heart Institute, Ottawa, ON K1Y 4W7, Canada
- Department of Radiology, University of Ottawa, Ottawa, ON K1Y 4W7, Canada
| | - Leonard Kritharides
- Department of Cardiology, Concord Hospital, Sydney Local Health District, Concord, NSW 2137, Australia
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Schulz A, Otton J, Hussain T, Miah T, Schuster A. Clinical Advances in Cardiovascular Computed Tomography: From Present Applications to Promising Developments. Curr Cardiol Rep 2024:10.1007/s11886-024-02110-w. [PMID: 39162955 DOI: 10.1007/s11886-024-02110-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/26/2024] [Indexed: 08/21/2024]
Abstract
PURPOSE OF THE REVIEW This review aims to provide a profound overview on most recent studies on the clinical significance of Cardiovascular Computed Tomography (CCT) in diagnostic and therapeutic pathways. Herby, this review helps to pave the way for a more extended but yet purposefully use in modern day cardiovascular medicine. RECENT FINDINGS In recent years, new clinical applications of CCT have emerged. Major applications include the assessment of coronary artery disease and structural heart disease, with corresponding recommendations by major guidelines of international societies. While CCT already allows for a rapid and non-invasive diagnosis, technical improvements enable further in-depth assessments using novel imaging parameters with high temporal and spatial resolution. Those developments facilitate diagnostic and therapeutic decision-making as well as improved prognostication. This review determined that recent advancements in both hardware and software components of CCT allow for highly advanced examinations with little radiation exposure. This particularly strengthens its role in preventive care and coronary artery disease. The addition of functional analyses within and beyond coronary artery disease offers solutions in wide-ranging patient populations. Many techniques still require improvement and validation, however, CCT possesses potential to become a "one-stop-shop" examination.
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Affiliation(s)
- Alexander Schulz
- Department of Cardiology and Pneumology, Georg-August University, University Medical Center, Göttingen, Germany
- Department of Medicine, Cardiovascular Division, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Ave, Boston, MA, 02215, USA
| | - James Otton
- South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Tarique Hussain
- Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK
- Departments of Paediatrics, Southwestern Medical Center, University of Texas, Dallas, TX, USA
| | - Tayaba Miah
- Division of Imaging Sciences and Biomedical Engineering, King's College London, London, UK
- Departments of Paediatrics, Southwestern Medical Center, University of Texas, Dallas, TX, USA
| | - Andreas Schuster
- Department of Cardiology and Pneumology, Georg-August University, University Medical Center, Göttingen, Germany.
- FORUM Cardiology, Rosdorf, Germany.
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3
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Arslan M, Schaap J, van Gorsel B, Aubanell A, Budde RPJ, Hirsch A, Smulders MW, Mihl C, Damman P, Sliwicka O, Habets J, Dubois EA, Dedic A. Coronary computed tomography angiography improves assessment of patients with acute chest pain and inconclusively elevated high-sensitivity troponins. Eur Radiol 2024:10.1007/s00330-024-10930-1. [PMID: 39150488 DOI: 10.1007/s00330-024-10930-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 05/14/2024] [Accepted: 06/03/2024] [Indexed: 08/17/2024]
Abstract
OBJECTIVES To determine whether coronary computed tomography angiography (CCTA) can improve the diagnostic work-up of patients with acute chest pain and inconclusively high-sensitivity troponins (hs-troponin). METHODS We conducted a prospective, blinded, observational, multicentre study. Patients aged 30-80 years presenting to the emergency department with acute chest pain and inconclusively elevated hs-troponins were included and underwent CCTA. The primary outcome was the diagnostic accuracy of ≥ 50% stenosis on CCTA to identify patients with type-1 non-ST-segment elevation acute coronary syndrome (NSTE-ACS). RESULTS A total of 106 patients (mean age 65 ± 10, 29% women) were enrolled of whom 20 patients (19%) had an adjudicated diagnosis of type-1 NSTE-ACS. In 45 patients, CCTA revealed non-obstructive coronary artery disease (CAD) or no CAD. Sensitivity, specificity, negative predictive value (NPV), positive predictive value and area-under-the-curve (AUC) of ≥ 50% stenosis on CCTA to identify patients with type 1 NSTE-ACS, was 95% (95% confidence interval: 74-100), 56% (45-68), 98% (87-100), 35% (29-41) and 0.83 (0.73-0.94), respectively. When only coronary segments with a diameter ≥ 2 mm were considered for the adjudication of type 1 NSTE-ACS, the sensitivity and NPV increased to 100%. In 8 patients, CCTA enabled the detection of clinically relevant non-coronary findings. CONCLUSION The absence of ≥ 50% coronary artery stenosis on CCTA can be used to rule out type 1 NSTE-ACS in acute chest pain patients with inconclusively elevated hs-troponins. Additionally, CCTA can help improve the diagnostic work-up by detecting other relevant conditions that cause acute chest pain and inconclusively elevated hs-troponins. CLINICAL RELEVANCE STATEMENT Coronary CTA (CCTA) can safely rule out type 1 non-ST-segment elevation acute coronary syndrome (NSTE-ACS) in patients presenting to the ED with acute chest pain and inconclusively elevated hs-troponins, while also detecting other relevant non-coronary conditions. TRIAL REGISTRATION Clinicaltrials.gov (NCT03129659). Registered on 26 April 2017 KEY POINTS: Acute chest discomfort is a common presenting complaint in the emergency department. CCTA achieved very high negative predictive values for type 1 NSTE-ACS in this population. CCTA can serve as an adjunct for evaluating equivocal ACS and evaluates for other pathology.
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Affiliation(s)
- Murat Arslan
- Department of Cardiology, Erasmus Medical Centre, University Medical Centre Rotterdam, Rotterdam, The Netherlands.
- Department of Radiology and Nuclear Medicine, Erasmus Medical Centre, University Medical Centre Rotterdam, Rotterdam, The Netherlands.
| | - Jeroen Schaap
- Department of Cardiology, Amphia Hospital, Breda, The Netherlands
| | - Bart van Gorsel
- Department of Cardiology, Amphia Hospital, Breda, The Netherlands
| | - Anton Aubanell
- Department of Radiology and Nuclear Medicine, Erasmus Medical Centre, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Ricardo P J Budde
- Department of Cardiology, Erasmus Medical Centre, University Medical Centre Rotterdam, Rotterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus Medical Centre, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Alexander Hirsch
- Department of Cardiology, Erasmus Medical Centre, University Medical Centre Rotterdam, Rotterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus Medical Centre, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Martijn W Smulders
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Casper Mihl
- Department of Radiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Peter Damman
- Department of Cardiology, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Olga Sliwicka
- Department of Radiology, Nuclear Medicine and Anatomy, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Jesse Habets
- Department of Radiology, Haaglanden Medical Centre, The Hague, The Netherlands
| | - Eric A Dubois
- Department of Cardiology, Erasmus Medical Centre, University Medical Centre Rotterdam, Rotterdam, The Netherlands
- Department of Intensive Care, Erasmus Medical Centre, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Admir Dedic
- Department of Cardiology, Erasmus Medical Centre, University Medical Centre Rotterdam, Rotterdam, The Netherlands
- Department of Cardiology, Noordwest Group, Alkmaar, The Netherlands
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Baggiano A, Baessato F, Mushtaq S, Annoni AD, Cannata F, Carerj ML, Del Torto A, Fazzari F, Formenti A, Frappampina A, Fusini L, Junod D, Mancini ME, Mantegazza V, Maragna R, Marchetti F, Sbordone FP, Tassetti L, Volpe A, Guglielmo M, Rossi A, Rovera C, Rabbat MG, Guaricci AI, Cau C, Saba L, Berna G, Sforza C, Pepi M, Pontone G. STress computed tomogRaphy perfusion and stress cArdiac magnetic resonance for ThE manaGement of suspected or known coronarY artery disease: resources and outcomes impact. J Cardiovasc Comput Tomogr 2024:S1934-5925(24)00403-9. [PMID: 39147676 DOI: 10.1016/j.jcct.2024.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 07/18/2024] [Accepted: 08/02/2024] [Indexed: 08/17/2024]
Abstract
BACKGROUND The aim of this study is to describe resources and outcomes of coronary computed tomography angiography plus Stress CT perfusion (CCTA + Stress-CTP) and stress cardiovascular magnetic resonance (Stress-CMR) in symptomatic patients with suspected or known CAD. METHODS Six hundred and twenty-four consecutive symptomatic patients with intermediate to high-risk pretest likelihood for CAD or previous history of revascularization referred to our hospital for clinically indicated CCTA + Stress-CTP or Stress-CMR were enrolled. Stress-CTP scans were performed in 223 patients while 401 patients performed Stress-CMR. Patient follow-up was performed at 1 year after index test performance. Endpoints were all cardiac events, as a combined endpoint of revascularization, non-fatal MI and death, and hard cardiac events, as combined endpoint of non-fatal MI and death. RESULTS Twenty-nine percent of patients who underwent CCTA + Stress-CTP received revascularization, 7% of subjects assessed with Stress-CMR were treated invasively, and a low number of non-fatal MI and death was observed with both strategies (hard events in 0.4% of patients that had CCTA + Stress-CTP as index test, and in 3% of patients evaluated with Stress-CMR). According to the predefined endpoints, CCTA + Stress-CTP group showed high rate of all cardiac events and low rate of hard cardiac events, respectively. The cumulative costs were 1970 ± 2506 Euro and 733 ± 1418 Euro for the CCTA + Stress-CTP group and Stress-CMR group, respectively. CONCLUSIONS The use of CCTA + Stress-CTP strategy was associated with high referral to revascularization but with a favourable trend in terms of hard cardiac events and diagnostic yield in identifying individuals at lower risk of adverse events despite the presence of CAD.
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Affiliation(s)
- Andrea Baggiano
- Centro Cardiologico Monzino IRCCS, Milan, Italy; Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Francesca Baessato
- Department of Cardiology, San Maurizio Regional Hospital, Bolzano, Italy
| | | | | | | | | | | | | | | | | | - Laura Fusini
- Centro Cardiologico Monzino IRCCS, Milan, Italy; Department of Electronics, Information and Biomedical engineering, Politecnico di Milano, Milan, Italy
| | | | | | | | | | | | | | | | | | - Marco Guglielmo
- Department of Cardiology, Division of Heart and Lungs, Utrecht University, Utrecht University Medical Center, Utrecht, the Netherlands; Department of Cardiology, Haga Teaching Hospital, The Hague, the Netherlands
| | - Alexia Rossi
- Department of Nuclear Medicine, University Hospital, Zurich, Switzerland; Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | | | - Mark G Rabbat
- Loyola University of Chicago, Chicago, IL, USA; Edward Hines Jr. VA Hospital, Hines, IL, USA
| | - Andrea Igoren Guaricci
- University Cardiology Unit, Interdisciplinary Department of Medicine, University of Bari Aldo Moro, Bari, Italy
| | - Claudio Cau
- Department of Medical Sciences, University of Cagliari, Cagliari, Italy
| | - Luca Saba
- Department of Medical Sciences, University of Cagliari, Cagliari, Italy
| | | | - Chiarella Sforza
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Mauro Pepi
- Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Gianluca Pontone
- Centro Cardiologico Monzino IRCCS, Milan, Italy; Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy.
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Nguyen ET, Green CR, Adams SJ, Bishop H, Gleeton G, Hague CJ, Hanneman K, Harris S, Strzelczyk J, Dennie C. CAR and CSTR Cardiac Computed Tomography (CT) Practice Guidelines: Part 1 Coronary CT Angiography (CCTA). Can Assoc Radiol J 2024; 75:488-501. [PMID: 38486401 DOI: 10.1177/08465371241233240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2024] Open
Abstract
Imaging the heart is one of the most technically challenging applications of Computed Tomography (CT) due to the presence of cardiac motion limiting optimal visualization of small structures such as the coronary arteries. Electrocardiographic gating during CT data acquisition facilitates motion free imaging of the coronary arteries. Since publishing the first version of the Canadian Association of Radiologists (CAR) cardiac CT guidelines, many technological advances in CT hardware and software have emerged necessitating an update. The goal of these cardiac CT practice guidelines is to present an overview of the current evidence supporting the use of cardiac CT in various clinical scenarios and to outline standards of practice for patient safety and quality of care when establishing a cardiac CT program in Canada.
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Affiliation(s)
- Elsie T Nguyen
- Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
| | | | - Scott J Adams
- Department of Medical Imaging, Royal University Hospital, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Helen Bishop
- Division of Cardiology, Department of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Guylaine Gleeton
- Department of Radiology, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Laval University, Quebec City, QC, Canada
| | - Cameron J Hague
- Department of Diagnostic Radiology, University of British Columbia, Vancouver, BC, Canada
| | - Kate Hanneman
- Department of Medical Imaging, University of Toronto, Toronto, ON, Canada
| | - Scott Harris
- Department of Radiology, Memorial University, St. John's, NL, Canada
| | - Jacek Strzelczyk
- Department of Radiology, University of Manitoba, Winnipeg, MB, Canada
| | - Carole Dennie
- Department of Radiology, Radiation Oncology and Medical Physics, University of Ottawa, Ottawa, ON, Canada
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6
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Sentagne JP, Ohana M, Severac F, Le Borgne P, Sauleau EA, Bilbault P, Kepka S. Diagnostic performance of coronary calcifications on CT to rule out acute coronary syndrome in the emergency department. BMC Emerg Med 2024; 24:116. [PMID: 38997628 PMCID: PMC11242020 DOI: 10.1186/s12873-024-01038-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2024] [Accepted: 07/04/2024] [Indexed: 07/14/2024] Open
Abstract
BACKGROUND At present, the diagnosis of acute coronary syndrome (ACS) can be made by emergency physicians using the usual complementary tests, since the current troponin and electrocardiogram (ECG) protocols have been extensively tested for their safety. However, the detection of coronary calcifications on CT associated with coronary obstruction may be of interest for the diagnostic strategy in the emergency department (ED). The aim of this study was to evaluate a strategy combining a non-ischemic ECG with an initial normal troponin assay and the diagnostic accuracy of chest CT in detecting coronary calcifications to rule out the presence of an acute coronary event in patients presenting with chest pain in the ED. METHODS This was a retrospective, single-center study carried out in an ED in France and included all patients over 18 years of age presenting with chest pain between 1 June 2021 and 31 December 2021 with a non-ischemic ECG and a negative first troponin assay. The primary endpoint was the diagnostic performance of the combing strategy in ruling out ACS. The secondary endpoints were the sensitivity and specificity of calcifications in acute coronary syndrome, comparison with the diagnostic performance of a second troponin assay and the rate of reconsultation, rehospitalisation and investigations within 2 months of the ED. RESULTS Of the 280 patients included, 141 didn't have calcifications. A total of 14 events were found with a negative predictive value for the combining strategy of 99.8% [95%CI: 98.2 - 100]. Sensitivity and specificity were 98.4% [95%CI: 83.8 - 100] and 53% [95%CI: 47 - 58.9], respectively. Among patients with no calcification, 8.2% were admitted to hospital and none suffered an acute coronary event. A total of 36 patients (12.8%) consulted a doctor within 2 months, with 23 investigations, all of which were negative in the non-calcification group. CONCLUSIONS A strategy combining the detection of coronary calcifications on chest CT in patients with a non-ischemic ECG and a single troponin assay is effective to rule out ACS in the ED, and may perform better then ECG and troponin alone.
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Affiliation(s)
- Julie Paget Sentagne
- Emergency Department, Hôpitaux Universitaires de Strasbourg, 1 Place de L'hôpital, CHRU of Strasbourg, 67091, Strasbourg, France
| | - Mickaël Ohana
- ICUBE UMR 7357 CNRS, Équipe IMAGeS, 300 Bd Sébastien Brant, 67400, Strasbourg, Illkirch-Graffenstaden, France
- Radiology Department, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, 1 Place de L'hôpital, 67091, Strasbourg, France
| | - François Severac
- ICUBE UMR 7357 CNRS, Équipe IMAGeS, 300 Bd Sébastien Brant, 67400, Strasbourg, Illkirch-Graffenstaden, France
- Groupe Méthodes en Recherche Clinique (GMRC), Hôpitaux Universitaires de Strasbourg, 1 Place de L'hôpital, 67091, Strasbourg, France
| | - Pierrick Le Borgne
- Emergency Department, Hôpitaux Universitaires de Strasbourg, 1 Place de L'hôpital, CHRU of Strasbourg, 67091, Strasbourg, France
- UMR 1260, INSERM / Université de Strasbourg CRBS, 1 Rue Eugene Boeckel, 67000, Strasbourg, France
| | - Erik-André Sauleau
- ICUBE UMR 7357 CNRS, Équipe IMAGeS, 300 Bd Sébastien Brant, 67400, Strasbourg, Illkirch-Graffenstaden, France
- Groupe Méthodes en Recherche Clinique (GMRC), Hôpitaux Universitaires de Strasbourg, 1 Place de L'hôpital, 67091, Strasbourg, France
| | - Pascal Bilbault
- Emergency Department, Hôpitaux Universitaires de Strasbourg, 1 Place de L'hôpital, CHRU of Strasbourg, 67091, Strasbourg, France
- UMR 1260, INSERM / Université de Strasbourg CRBS, 1 Rue Eugene Boeckel, 67000, Strasbourg, France
| | - Sabrina Kepka
- Emergency Department, Hôpitaux Universitaires de Strasbourg, 1 Place de L'hôpital, CHRU of Strasbourg, 67091, Strasbourg, France.
- ICUBE UMR 7357 CNRS, Équipe IMAGeS, 300 Bd Sébastien Brant, 67400, Strasbourg, Illkirch-Graffenstaden, France.
- Groupe Méthodes en Recherche Clinique (GMRC), Hôpitaux Universitaires de Strasbourg, 1 Place de L'hôpital, 67091, Strasbourg, France.
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Williams C, Van Ligten MJ, Tomlinson B, Kelly R, Wang CE, Root E, Swan MJ, Hodgson NR, Rappaport D, Martini WA. Challenges and Successes in Introducing Coronary CT Angiography in an Emergency Medicine-Run Observation Unit. Cureus 2024; 16:e63620. [PMID: 39092387 PMCID: PMC11291183 DOI: 10.7759/cureus.63620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2024] [Indexed: 08/04/2024] Open
Abstract
This study was designed to analyze the departmental changes in transitioning the Emergency Department (ED)-run Observation Medicine Unit's routine noninvasive cardiac evaluation from the traditional standard-of-care procedures to coronary computed tomography angiography (CCTA). While the routine use of CCTA for the evaluation of chest pain has been deemed feasible and safe, provider confidence appears apprehensive, and ordering patterns appear reluctant to change. We conducted a retrospective analysis of data from two risk-matched cohorts of ED patients who presented with symptoms suggestive of acute coronary syndrome (ACS) but without ischemic electrocardiogram (ECG) changes or positive troponin. Endpoints included length of stay, major adverse cardiovascular event (MACE) rates at 28 days, recidivism rate, and downstream findings on coronary catheterization. The adoption of CCTA led to a significant reduction in the length of stay for patients in the ED-run Observation Medicine Unit. Provider and nursing education initiatives were crucial in overcoming initial resistance and improving the implementation of CCTA. Post-education, there was a marked increase in the volume of CCTA performed and a decrease in the length of stay, enhancing overall departmental throughput. The results suggest that CCTA offers a reliable and efficient diagnostic alternative to traditional noninvasive tests, with high diagnostic accuracy contributing to faster decision-making and reduced need for invasive procedures. Continuous education for providers and nursing staff was essential to ensure adherence to the new protocol and improve clinical outcomes. Transitioning to CCTA for routine noninvasive cardiac evaluation in the ED-run Observation Medicine Unit demonstrated significant efficiency and diagnostic accuracy benefits. Successful implementation requires targeted educational efforts to ensure competency and confidence among healthcare providers. The findings support the integration of CCTA into standard clinical practice for the evaluation of chest pain in the emergency setting, with future research needed to validate these results in broader patient populations and assess long-term outcomes.
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Affiliation(s)
- Catherine Williams
- Department of Emergency Medicine, Mayo Clinic Alix School of Medicine, Scottsdale, USA
| | - Matthew J Van Ligten
- Department of Emergency Medicine, Mayo Clinic Alix School of Medicine, Scottsdale, USA
| | - Brianna Tomlinson
- Department of Emergency Medicine, Mayo Clinic Alix School of Medicine, Scottsdale, USA
| | - Robert Kelly
- Department of Emergency Medicine, Mayo Clinic Alix School of Medicine, Scottsdale, USA
| | - Charis E Wang
- Department of Emergency Medicine, Mayo Clinic Alix School of Medicine, Scottsdale, USA
| | - Erin Root
- Department of Hospital Internal Medicine, Mayo Clinic Arizona, Phoenix, USA
| | - Matthew J Swan
- Department of Hospital Internal Medicine, Mayo Clinic Arizona, Phoenix, USA
| | - Nicole R Hodgson
- Department of Emergency Medicine, Mayo Clinic in Arizona, Phoenix, USA
| | - Douglas Rappaport
- Department of Emergency Medicine, Mayo Clinic in Arizona, Phoenix, USA
| | - Wayne A Martini
- Department of Emergency Medicine, Mayo Clinic in Arizona, Phoenix, USA
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8
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Mansouri P, Nematipour E, Rajablou N, Ghorashi SM, Azari S, Omidi N. Left anterior descending coronary artery-left circumflex coronary artery bifurcation angle and severity of coronary artery disease; is there any correlation? A cross-sectional study. Health Sci Rep 2024; 7:e2182. [PMID: 38868537 PMCID: PMC11168269 DOI: 10.1002/hsr2.2182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 04/05/2024] [Accepted: 05/16/2024] [Indexed: 06/14/2024] Open
Abstract
Background and Aims The aim of this study is to evaluate the association of coronary computed tomography angiography derived (CCTA) plaque characteristics and the left anterior descending coronary artery (LAD) and left circumflex coronary artery (LCX) bifurcation angle with severity of coronary artery disease (CAD). Methods All the stable patients with suspected CAD who underwent CCTA between January to December 2021 were included. Correlation between CCTA-derived aggregated plaque volume (APV), LAD-LCX angle, remodeling index (RI), coronary calcium score with Gensini score in conventional angiography were assessed. One hundred and twenty-two patients who underwent both CCTA and coronary angiography were analyzed. Results Our analysis showed that the median (percentile 25% to percentile 75%) of the APV, LAD-LCx angle, and calcium score were 31% (17%-47%), 58° (39°-89°), and 31 (0-186), respectively. Also, the mean ± SD of the RI was 1.05 ± 0.20. Significant correlation between LAD-LCx bifurcation angle (0.0001-0.684), APV (0.002-0.281), RI (0.0001-0.438), and calcium score (0.016-0.217) with Gensini score were detected. There was a linear correlation between the mean LAD-LCx bifurcation angle and the Gensini score. The sensitivity and specificity for the cut-off value of 47.5° for the LAD-LCX angle were 86.7% and 82.1%, respectively. Conclusion There is a direct correlation between the LAD-LCx angle and the Gensini score. In addition to plaque characteristics, anatomic-based CCTA-derived indices can be used to identify patients at higher risk for CAD.
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Affiliation(s)
- Pejman Mansouri
- Tehran Heart Center, Cardiovascular Disease Research InstituteTehran University of Medical SciencesTehranIran
| | - Ebrahim Nematipour
- Tehran Heart Center, Cardiovascular Disease Research InstituteTehran University of Medical SciencesTehranIran
| | - Nadia Rajablou
- School of MedicineTehran University of Medical SciencesTehranIran
| | - Seyyed Mojtaba Ghorashi
- Tehran Heart Center, Cardiovascular Disease Research InstituteTehran University of Medical SciencesTehranIran
| | - Samad Azari
- Hospital Management Research Center, Health Management Research InstituteIran University of Medical SciencesTehranIran
- Research Center for Emergency and Disaster ResilienceRed Crescent Society of the Islamic Republic of IranTehranIran
| | - Negar Omidi
- Cardiovascular Imaging Departement, Tehran Heart Center, School of Medicin, Tehran University of Medical SciencesTehran heart centerTehranIran
- Cardiac Primary Prevention Research Center, Cardiovascular Institute, Tehran University of Medical ScienceTehran heart centerTehranIran
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9
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Lee E, Amadi C, Williams MC, Agarwal PP. Coronary Artery Disease: Role of Computed Tomography and Recent Advances. Radiol Clin North Am 2024; 62:385-398. [PMID: 38553176 DOI: 10.1016/j.rcl.2023.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
In this review, the authors summarize the role of coronary computed tomography angiography and coronary artery calcium scoring in different clinical presentations of chest pain and preventative care and discuss future directions and new technologies such as pericoronary fat inflammation and the growing footprint of artificial intelligence in cardiovascular medicine.
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Affiliation(s)
- Elizabeth Lee
- Department of Radiology, Michigan Medicine, 1500 East Medical Center Drive, TC B1-148, Ann Arbor, MI 48109-5030, USA.
| | - Chiemezie Amadi
- Department of Radiology, Michigan Medicine, 1500 Medical Center Drive, Room 5481, Ann Arbor, MI 48109-5868, USA
| | - Michelle C Williams
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, The Queen's Medical Research Institute, Edinburg BioQuarter, 47 Little France Crescent, Edinburgh EH16 4TJ, UK
| | - Prachi P Agarwal
- Department of Radiology, Division of Cardiothoracic Radiology, Michigan Medicine, 1500 East Medical Center Drive SPC 5868, Ann Arbor, MI 48109, USA
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Mahler SA, Ashburn NP, Supples MW, Hashemian T, Snavely AC. Validation of the ACC Expert Consensus Decision Pathway for Patients With Chest Pain. J Am Coll Cardiol 2024; 83:1181-1190. [PMID: 38538196 DOI: 10.1016/j.jacc.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 01/30/2024] [Accepted: 02/01/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND The American College of Cardiology (ACC) recently published an Expert Consensus Decision Pathway for chest pain. OBJECTIVES The purpose of this study was to validate the ACC Pathway in a multisite U.S. COHORT METHODS An observational cohort study of adults with possible acute coronary syndrome was conducted. Patients were accrued from 5 U.S. Emergency Departments (November 1, 2020, to July 31, 2022). ECGs and 0- and 2-hour high-sensitivity troponin (Beckman Coulter) measures were used to stratify patients according to the ACC Pathway. The primary safety outcome was 30-day all-cause death or myocardial infarction (MI). Efficacy was defined as the proportion stratified to the rule-out zone. Negative predictive value for 30-day death or MI was assessed among the whole cohort and in a subgroup of patients with coronary artery disease (CAD) (prior MI, revascularization, or ≥70% coronary stenosis). RESULTS ACC Pathway assessments were complete in 14,395 patients, of whom 51.7% (7,437 of 14,395) were women with a median age of 56 years (Q1-Q3: 44-68 years). Known CAD was present in 23.5% (3,386 of 14,395) and 30-day death or MI occurred in 8.1% (1,168 of 14,395). The ACC Pathway had an efficacy of 48.1% (95% CI: 47.3%-49.0%). Among patients in the rule-out zone, 0.3% (22 of 6,930) had death or MI at 30 days, yielding a negative predictive value of 99.7% (95% CI: 99.5%-99.8%). In patients with known CAD, 20.0% (676 of 3,386) were classified to the rule-out zone, of whom 1.5% (10 of 676) had death or MI. CONCLUSIONS The ACC expert consensus decision pathway was safe and efficacious. However, it may not be safe for use among patients with known CAD.
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Affiliation(s)
- Simon A Mahler
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA; Department of Epidemiology and Prevention, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA; Department of Implementation Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA.
| | - Nicklaus P Ashburn
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Michael W Supples
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Tara Hashemian
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Anna C Snavely
- Department of Emergency Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA; Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
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11
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Jehangir M, Hippe DS, Huang G, Robinson JD. Limited Axial Interpretation of Coronary CT Angiography in the Emergency Department Setting. J Am Coll Radiol 2024; 21:591-600. [PMID: 37201689 DOI: 10.1016/j.jacr.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 04/07/2023] [Accepted: 04/12/2023] [Indexed: 05/20/2023]
Abstract
PURPOSE Incorporating coronary CT angiographic (CCTA) imaging into emergency department (ED) workflows has been limited by the need for 24/7 real-time postprocessing. The aim of this study was to determine whether interpretation of transaxial CCTA images alone (limited axial interpretation [LI]) is noninferior to interpretation of combined transaxial and multiplanar reformation images (full interpretation [FI]) in assessing patients with acute chest pain in the ED. METHODS CCTA examinations from 74 patients were evaluated by two radiologists, one without dedicated CCTA training and one with basic CCTA experience. Each examination was evaluated three times in separate sessions, once by LI and twice by FI, in random order. Nineteen coronary artery segments were rated as having significant stenoses (≥50%) or not. Interreader agreement was assessed using Cohen's κ statistic. The primary analysis was whether the accuracy of LI for detecting significant stenosis was noninferior to that of FI at the patient level (margin = -10%). Secondary analyses included similar analyses of sensitivity and specificity, at both the patient and vessel levels. RESULTS Interreader agreement for significant stenosis was good for both LI and FI (κ = 0.72 vs 0.70, P = .74). Average accuracy for significant stenosis at the patient level was 90.5% for LI and 91.9% for FI, with a difference of -1.4%. The accuracy of LI was noninferior to FI, because the confidence interval did not include the noninferiority margin. Noninferiority was also found for patient-level sensitivity and for accuracy, sensitivity, and specificity at the vessel level. CONCLUSIONS LI of the coronary arteries using transaxial CCTA images may be sufficient for the detection of significant coronary artery disease in the ED setting.
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Affiliation(s)
- Maham Jehangir
- Department or Radiology, University of Washington, Seattle, Washington
| | - Daniel S Hippe
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Gary Huang
- Department of Cardiology, University of Washington, Seattle, Washington
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12
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Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Jüni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B. 2023 ESC Guidelines for the management of acute coronary syndromes. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:55-161. [PMID: 37740496 DOI: 10.1093/ehjacc/zuad107] [Citation(s) in RCA: 32] [Impact Index Per Article: 32.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/24/2023]
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13
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Dani A, Shah P, Desai D. Noninvasive imaging modalities in coronary artery disease: a meta analysis comparing coronary computed tomography angiography and standard of care. Future Cardiol 2024; 20:81-88. [PMID: 38275185 DOI: 10.2217/fca-2023-0103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 12/22/2023] [Indexed: 01/27/2024] Open
Abstract
Introduction: Coronary artery disease has become a global pandemic and a major cause of death. The risk-factor calculation for coronary artery damage is an invasive procedure. Aim: To compare coronary computed tomography angiography (CCTA) with standard of care (SOC) to calculate need for revascularization, invasive coronary angiography as well as for myocardial infarction (MI) incidence and all-cause mortality. Methodology, results & conclusion: CCTA is significantly correlated with a reduction in MI episodes (RR = 0.752, 95% CI = 0.578-1.409; p < 0.033) and an increase in revascularizations (RR = 1.401, 95% CI = 1.315-1.492; p < 0.001) and invasive coronary angiography procedures (RR = 1.304, 95% CI = 1.208-1.409; p < 0.001). However, it was found that it did not affect all-cause mortality. On the contrary, standard care approaches were associated with greater rates of MI but lesser referrals for invasive coronary angiography and revascularization.
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Affiliation(s)
- Avichal Dani
- Shri Nathiba Hargovandas Lakhmichand Municipal Medical College, Ahmedabad 380006, India
| | - Pari Shah
- Shri Nathiba Hargovandas Lakhmichand Municipal Medical College, Ahmedabad 380006, India
| | - Dev Desai
- Shri Nathiba Hargovandas Lakhmichand Municipal Medical College, Ahmedabad 380006, India
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14
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Lan NSR, Thomas DR, Jones CL, Raju V, Soon J, Otto J, Wood C, Briffa T, Dwivedi G, Rankin JM, Ihdayhid AR. Evaluation of stable chest pain following emergency department presentation: Impact of first-line cardiac computed tomography diagnostic strategy in an Australian setting. Emerg Med Australas 2024; 36:31-38. [PMID: 37593996 DOI: 10.1111/1742-6723.14290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/17/2023] [Accepted: 07/19/2023] [Indexed: 08/19/2023]
Abstract
OBJECTIVE International guidelines provide increasing support for computed tomography coronary angiography (CTCA) in investigating chest pain. A pathway utilising CTCA first-line for outpatient stable chest pain evaluation was implemented in an Australian ED. METHODS In pre-post design, the impact of the pathway was prospectively assessed over 6 months (August 2021 to January 2022) and compared with a 6-month pre-implementation group (February 2021 to July 2021). CTCA was recommended first-line in suspected stable cardiac chest pain, followed by chest pain clinic review. Predefined criteria were provided recommending functional testing in select patients. The impact of CTCA versus functional testing was evaluated. Data were obtained from digital medical records. RESULTS Three hundred and fifteen patients were included, 143 pre-implementation and 172 post-implementation. Characteristics were similar except age (pre-implementation: 58.9 ± 12.0 vs post-implementation: 62.8 ± 12.3 years, P = 0.004). Pathway-guided management resulted in higher first-line CTCA (73.3% vs 46.2%, P < 0.001), lower functional testing (30.2% vs 56.6%, P < 0.001) and lower proportion undergoing two non-invasive tests (4.7% vs 10.5%, P = 0.047), without increasing investigation costs or invasive coronary angiography (ICA) (pre-implementation: 13.3% vs post-implementation: 9.3%, P = 0.263). In patients undergoing CTCA, 40.7% had normal coronaries and 36.2% minimal/mild disease, with no difference in disease burden post-implementation. More medication changes occurred following CTCA compared with functional testing (aspirin: P = 0.005, statin: P < 0.001). In patients undergoing ICA, revascularisation to ICA ratio was higher following CTCA compared with functional testing (91.7% vs 18.2%, P < 0.001). No 30-day myocardial infarction or death occurred. CONCLUSIONS The pathway increased CTCA utilisation and reduced downstream investigations. CTCA was associated with medication changes and improved ICA efficiency.
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Affiliation(s)
- Nick S R Lan
- Department of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
- Medical School, Harry Perkins Institute of Medical Research, The University of Western Australia, Perth, Western Australia, Australia
| | - David-Raj Thomas
- Department of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Christopher L Jones
- Department of Emergency Medicine, Fiona Stanley Hospital, Perth, Western Australia, Australia
- School of Medicine, The University of Notre Dame Australia, Fremantle, Western Australia, Australia
| | - Vikram Raju
- Department of Radiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Jeanette Soon
- Department of Radiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Jacobus Otto
- Department of Radiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Chris Wood
- Department of Radiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Tom Briffa
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Girish Dwivedi
- Department of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
- Medical School, Harry Perkins Institute of Medical Research, The University of Western Australia, Perth, Western Australia, Australia
| | - James M Rankin
- Department of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Abdul Rahman Ihdayhid
- Department of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
- Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia
- Curtin Medical School, Curtin University, Perth, Western Australia, Australia
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15
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Matsumoto AH, Dake MD. Implications of IR Being a Primary Specialty on the Professional Organizational Relationship between Interventional and Diagnostic Radiology. J Vasc Interv Radiol 2023; 34:2080-2084. [PMID: 38008543 DOI: 10.1016/j.jvir.2023.08.011] [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: 06/14/2023] [Accepted: 08/12/2023] [Indexed: 11/28/2023] Open
Abstract
The recent awarding of primary specialty status to interventional radiology (IR) invites a re-examination of the long-standing relationship between IR and diagnostic radiology (DR). In this new era, it is important to evaluate how the organizations that represent these 2 specialties can best contribute to strengthening a growth in collaborations and partnerships that will benefit their members and patients. Areas of organizational focus with the potential to enhance the future for both groups include combining efforts directed toward advocacy and government relations, developing practice models to create successful IR and DR working relationships, and providing more data to demonstrate the value of IR above and beyond the work relative value units and professional revenues that IR generates.
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Affiliation(s)
- Alan H Matsumoto
- Department of Radiology and Medical Imaging, University of Virginia Health, Charlottesville, Virginia.
| | - Michael D Dake
- Department of Medical Imaging, Surgery and Medicine, University of Arizona Health Sciences, Tucson Campus, Health Sciences Innovation Building, Tucson, Arizona
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16
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Wang KL, Meah MN, Bularga A, Oatey K, O'Brien R, Smith JE, Curzen N, Kardos A, Keating L, Felmeden D, Storey RF, Goodacre S, Roobottom C, Newby DE, Gray AJ. Early computed tomography coronary angiography and preventative treatment in patients with suspected acute coronary syndrome: A secondary analysis of the RAPID-CTCA trial. Am Heart J 2023; 266:138-148. [PMID: 37709109 DOI: 10.1016/j.ahj.2023.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 09/01/2023] [Accepted: 09/06/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND Computed tomography coronary angiography (CTCA) offers detailed assessment of the presence of coronary atherosclerosis and helps guide patient management. We investigated influences of early CTCA on the subsequent use of preventative treatment in patients with suspected acute coronary syndrome. METHODS In this secondary analysis of a multicenter randomized controlled trial of early CTCA in intermediate-risk patients with suspected acute coronary syndrome, prescription of aspirin, P2Y12 receptor antagonist, statin, renin-angiotensin system blocker, and beta-blocker therapies from randomization to discharge were compared within then between those randomized to early CTCA or to standard of care only. Effects of CTCA findings on adjustment of these therapies were further examined. RESULTS In 1,743 patients (874 randomized to early CTCA and 869 to standard of care only), prescription of P2Y12 receptor antagonist, dual antiplatelet, and statin therapies increased more in the early CTCA group (between-group difference: 4.6% [95% confidence interval, 0.3-8.9], 4.5% [95% confidence interval, 0.2-8.7], and 4.3% [95% confidence interval, 0.2-8.5], respectively), whereas prescription of other preventative therapies increased by similar extent in both study groups. Among patients randomized to early CTCA, there were additional increments of preventative treatment in those with obstructive coronary artery disease and higher rates of reductions in antiplatelet and beta-blocker therapies in those with normal coronary arteries. CONCLUSIONS Prescription patterns of preventative treatment varied during index hospitalization in patients with suspected acute coronary syndrome. Early CTCA facilitated targeted individualization of these therapies based on the extent of coronary artery disease.
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Affiliation(s)
- Kang-Ling Wang
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan; General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan.
| | - Mohammed N Meah
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Anda Bularga
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Katherine Oatey
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, United Kingdom
| | - Rachel O'Brien
- Department of Emergency Medicine, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Jason E Smith
- Emergency Department, University Hospitals Plymouth NHS Trust, Plymouth, United Kingdom
| | - Nick Curzen
- Faculty of Medicine, University of Southampton, Southampton, United Kingdom; Department of Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Attila Kardos
- Department of Cardiology, Milton Keynes University Hospital NHS Foundation Trust, Milton Keynes, United Kingdom; Faculty of Medicine and Health Science, University of Buckingham, Buckingham, United Kingdom
| | - Liza Keating
- Department of Emergency Medicine, Royal Berkshire NHS Foundation Trust, Reading, United Kingdom
| | - Dirk Felmeden
- Department of Cardiology, Torbay and South Devon NHS Foundation Trust, Torquay, United Kingdom
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Steve Goodacre
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Carl Roobottom
- Department of Radiology, University Hospitals Plymouth NHS Trust, Plymouth, United Kingdom; Faculty of Health, University of Plymouth, Plymouth, United Kingdom
| | - David E Newby
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Alasdair J Gray
- Department of Emergency Medicine, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom; Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
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17
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Giubbini R, Paghera B, Dondi M, Estrada Lobato E, Peix A, Paez D. Critical Appraisal of the Current Role of Myocardial Perfusion Imaging in the Management of Acute Chest Pain. Semin Nucl Med 2023; 53:733-742. [PMID: 37722928 DOI: 10.1053/j.semnuclmed.2023.08.003] [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: 04/12/2023] [Revised: 08/14/2023] [Accepted: 08/17/2023] [Indexed: 09/20/2023]
Abstract
This paper describes the evolution of nuclear cardiology techniques in the setting of acute coronary syndromes. Since the 1970s, the contribution of nuclear cardiology has been fundamental in delineating the physiopathology and diagnosis of acute myocardial infarction, when electrocardiogram (ECG) did not provide the diagnosis and when cardiac enzyme assessments were at a very early stage. In this clinical situation, at that time the role of pyrophosphate scintigraphy and antimyosin antibodies was important in ensuring diagnostic precision. However, these methods showed limitations and were abandoned in the late 80s and early 90s when therapeutic applications such as thrombolytic therapy, and primary-and rescue-percutaneous coronary intervention (PCI) were introduced. Beginning in the mid-80s, the introduction and widespread use of perfusion tracers such as 99mTc labelled compounds and technological advances such as SPECT, allowed to assess the efficacy of thrombolysis and early revascularization, as well as to assess in depth myocardial salvage. Currently, perfusion SPECT, especially using fast imaging techniques and dedicated cardiac SPECT with solid-state detectors, allows a quick confirmation or exclusion of acute coronary syndromes, particularly in low-to-intermediate likelihood of coronary artery disease (CAD), especially when there are absolute or relative contraindications to the use of coronary computed tomographic angiography (CCTA).
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Affiliation(s)
- Raffaele Giubbini
- Department of Nuclear Medicine, University of Brescia, Brescia, Italy
| | - Barbara Paghera
- Department of Nuclear Medicine, Nuclear Medicine Unit, University of Brescia, Brescia, Italy
| | - Maurizio Dondi
- Department of Nuclear Medicine, Nuclear Medicine and Diagnostic Imaging Section, Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Austria
| | - Enrique Estrada Lobato
- Department of Nuclear Medicine, Nuclear Medicine and Diagnostic Imaging Section, Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Austria
| | - Amalia Peix
- Department of Nuclear Medicine, Institute of Cardiology, Havana, Cuba
| | - Diana Paez
- Department of Nuclear Medicine, Nuclear Medicine and Diagnostic Imaging Section, Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Austria.
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18
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Byrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A, Claeys MJ, Dan GA, Dweck MR, Galbraith M, Gilard M, Hinterbuchner L, Jankowska EA, Jüni P, Kimura T, Kunadian V, Leosdottir M, Lorusso R, Pedretti RFE, Rigopoulos AG, Rubini Gimenez M, Thiele H, Vranckx P, Wassmann S, Wenger NK, Ibanez B. 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J 2023; 44:3720-3826. [PMID: 37622654 DOI: 10.1093/eurheartj/ehad191] [Citation(s) in RCA: 758] [Impact Index Per Article: 758.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/26/2023] Open
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19
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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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20
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Greer C, Williams MC, Newby DE, Adamson PD. Role of computed tomography cardiac angiography in acute chest pain syndromes. Heart 2023; 109:1350-1356. [PMID: 36914247 DOI: 10.1136/heartjnl-2022-321360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 02/27/2023] [Indexed: 03/16/2023] Open
Abstract
Use of CT coronary angiography (CTCA) to evaluate chest pain has rapidly increased over the recent years. While its utility in the diagnosis of coronary artery disease in stable chest pain syndromes is clear and is strongly endorsed by international guidelines, the role of CTCA in the acute setting is less certain. In the low-risk setting, CTCA has been shown to be accurate, safe and efficient but inherent low rates of adverse events in this population and the advent of high-sensitivity troponin testing have left little room for CTCA to show any short-term clinical benefit.In higher-risk populations, CTCA has potential to fulfil a gatekeeper role to invasive angiography. The high negative predictive value of CTCA is maintained while also identifying non-obstructive coronary disease and alternative diagnoses in the substantial group of patients presenting with chest pain who do not have type 1 myocardial infarction. For those with obstructive coronary disease, CTCA provides accurate assessment of stenosis severity, characterisation of high-risk plaque and findings associated with perivascular inflammation. This may allow more appropriate selection of patients to proceed to invasive management with no disadvantage in outcomes and can provide a more comprehensive risk stratification to guide both acute and long-term management than routine invasive angiography.
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Affiliation(s)
- Charlotte Greer
- Christchurch Heart Institute, University of Otago Christchurch, Christchurch, Canterbury, New Zealand
| | | | - David E Newby
- Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK
| | - Philip D Adamson
- Christchurch Heart Institute, University of Otago Christchurch, Christchurch, Canterbury, New Zealand
- Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK
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21
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Barbosa MF, Canan A, Xi Y, Litt H, Diercks DB, Abbara S, Kay FU. Comparative Effectiveness of Coronary CT Angiography and Standard of Care for Evaluating Acute Chest Pain: A Living Systematic Review and Meta-Analysis. Radiol Cardiothorac Imaging 2023; 5:e230022. [PMID: 37693194 PMCID: PMC10483255 DOI: 10.1148/ryct.230022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 06/26/2023] [Accepted: 07/03/2023] [Indexed: 09/12/2023]
Abstract
Purpose To perform a living systematic review and meta-analysis of randomized controlled trials comparing the effectiveness of coronary CT angiography (CCTA) and standard of care (SOC) in the evaluation of acute chest pain (ACP). Materials and Methods Multiple electronic databases were systematically searched, with the most recent search conducted on October 31, 2022. Studies were stratified into two groups according to the pretest probability for acute coronary syndrome (group 1 with predominantly low-to-intermediate risk vs group 2 with high risk). A meta-regression analysis was also conducted using participant risk, type of SOC used, and the use or nonuse of high-sensitivity troponins as independent variables. Results The final analysis included 22 randomized controlled trials (9379 total participants; 4956 assigned to CCTA arms and 4423 to SOC arms). There was a 14% reduction in the length of stay and a 17% reduction in immediate costs for the CCTA arm compared with the SOC arm. In group 1, the length of stay was 17% shorter and costs were 21% lower using CCTA. There was no evidence of differences in referrals to invasive coronary angiography, myocardial infarction, mortality, rate of hospitalization, further stress testing, or readmissions between CCTA and SOC arms. There were more revascularizations (relative risk, 1.45) and medication changes (relative risk, 1.33) in participants with low-to-intermediate acute coronary syndrome risk and increased radiation exposure in high-risk participants (mean difference, 7.24 mSv) in the CCTA arm compared with the SOC arm. The meta-regression analysis found significant differences between CCTA and SOC arms for rate of hospitalization, further stress testing, and medication changes depending on the type of SOC (P < .05). Conclusion The results support the use of CCTA as a safe, rapid, and less expensive in the short term strategy to exclude acute coronary syndrome in low- to intermediate-risk patients presenting with acute chest pain.Keywords: Acute Coronary Syndrome, Chest Pain, Emergency Department, Coronary Computed Tomography, Usual Care Supplemental material is available for this article. Published under a CC BY 4.0 license.
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Affiliation(s)
- Maurício F. Barbosa
- From the Department of Radiology, Cardiothoracic Division (M.F.B.,
A.C., S.A., F.U.K.), Department of Radiology (Y.X.), and Department of Emergency
Medicine (D.B.D.), UT Southwestern Medical Center at Dallas, 5323 Harry Hines
Blvd, Dallas, TX 75390; and Department of Radiology, University of Pennsylvania,
Philadelphia, Pa (H.L.)
| | - Arzu Canan
- From the Department of Radiology, Cardiothoracic Division (M.F.B.,
A.C., S.A., F.U.K.), Department of Radiology (Y.X.), and Department of Emergency
Medicine (D.B.D.), UT Southwestern Medical Center at Dallas, 5323 Harry Hines
Blvd, Dallas, TX 75390; and Department of Radiology, University of Pennsylvania,
Philadelphia, Pa (H.L.)
| | - Yin Xi
- From the Department of Radiology, Cardiothoracic Division (M.F.B.,
A.C., S.A., F.U.K.), Department of Radiology (Y.X.), and Department of Emergency
Medicine (D.B.D.), UT Southwestern Medical Center at Dallas, 5323 Harry Hines
Blvd, Dallas, TX 75390; and Department of Radiology, University of Pennsylvania,
Philadelphia, Pa (H.L.)
| | - Harold Litt
- From the Department of Radiology, Cardiothoracic Division (M.F.B.,
A.C., S.A., F.U.K.), Department of Radiology (Y.X.), and Department of Emergency
Medicine (D.B.D.), UT Southwestern Medical Center at Dallas, 5323 Harry Hines
Blvd, Dallas, TX 75390; and Department of Radiology, University of Pennsylvania,
Philadelphia, Pa (H.L.)
| | - Deborah B. Diercks
- From the Department of Radiology, Cardiothoracic Division (M.F.B.,
A.C., S.A., F.U.K.), Department of Radiology (Y.X.), and Department of Emergency
Medicine (D.B.D.), UT Southwestern Medical Center at Dallas, 5323 Harry Hines
Blvd, Dallas, TX 75390; and Department of Radiology, University of Pennsylvania,
Philadelphia, Pa (H.L.)
| | - Suhny Abbara
- From the Department of Radiology, Cardiothoracic Division (M.F.B.,
A.C., S.A., F.U.K.), Department of Radiology (Y.X.), and Department of Emergency
Medicine (D.B.D.), UT Southwestern Medical Center at Dallas, 5323 Harry Hines
Blvd, Dallas, TX 75390; and Department of Radiology, University of Pennsylvania,
Philadelphia, Pa (H.L.)
| | - Fernando U. Kay
- From the Department of Radiology, Cardiothoracic Division (M.F.B.,
A.C., S.A., F.U.K.), Department of Radiology (Y.X.), and Department of Emergency
Medicine (D.B.D.), UT Southwestern Medical Center at Dallas, 5323 Harry Hines
Blvd, Dallas, TX 75390; and Department of Radiology, University of Pennsylvania,
Philadelphia, Pa (H.L.)
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22
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Bellino M, Silverio A, Esposito L, Cancro FP, Ferruzzi GJ, Di Maio M, Rispoli A, Vassallo MG, Di Muro FM, Galasso G, De Luca G. Moving toward Precision Medicine in Acute Coronary Syndromes: A Multimodal Assessment of Non-Culprit Lesions. J Clin Med 2023; 12:4550. [PMID: 37445584 DOI: 10.3390/jcm12134550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Revised: 07/01/2023] [Accepted: 07/05/2023] [Indexed: 07/15/2023] Open
Abstract
Patients with acute coronary syndrome and multivessel disease experience several recurrent adverse events that lead to poor outcomes. Given the complexity of treating these patients, and the extremely high risk of long-term adverse events, the assessment of non-culprit lesions becomes crucial. Recently, two trials have shown a possible clinical benefit into treat non-culprit lesions using a fraction flow reserve (FFR)-guided approach, compared to culprit-lesion-only PCI. However, the most recent FLOW Evaluation to Guide Revascularization in Multivessel ST-elevation Myocardial Infarction (FLOWER-MI) trial did not show a benefit of the use of FFR-guided PCI compared to an angiography-guided approach. Otherwise, intracoronary imaging using optical coherence tomography (OCT), intravascular ultrasound (IVUS), or near-infrared spectroscopy (NIRS) could provide both quantitative and qualitative assessments of non-culprit lesions. Different studies have shown how the characterization of coronary lesions with intracoronary imaging could lead to clinical benefits in these peculiar group of patients. Moreover, non-invasive evaluations of NCLs have begun to take ground in this context, but more insights through adequately powered and designed studies are needed. The aim of this review is to outline the available techniques, both invasive and non-invasive, for the assessment of multivessel disease in patients with STEMI, and to provide a systematic guidance on the assessment and approach to these patients.
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Affiliation(s)
- Michele Bellino
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84084 Baronissi, Italy
| | - Angelo Silverio
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84084 Baronissi, Italy
| | - Luca Esposito
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84084 Baronissi, Italy
| | - Francesco Paolo Cancro
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84084 Baronissi, Italy
| | - Germano Junior Ferruzzi
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84084 Baronissi, Italy
| | - Marco Di Maio
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84084 Baronissi, Italy
| | - Antonella Rispoli
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84084 Baronissi, Italy
| | - Maria Giovanna Vassallo
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84084 Baronissi, Italy
| | - Francesca Maria Di Muro
- Structural Interventional Cardiology, Department of Clinical and Experimental Medicine, Clinica Medica, Careggi University Hospital, 50139 Florence, Italy
| | - Gennaro Galasso
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84084 Baronissi, Italy
| | - Giuseppe De Luca
- Division of Cardiology, AOU "Policlinico G. Martino", Department of Clinical and Experimental Medicine, University of Messina, 98166 Messina, Italy
- Division of Cardiology, IRCCS Hospital Galeazzi-Sant'Ambrogio, 20161 Milan, Italy
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23
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Knudsen AD, Fuchs A, Benfield T, Gerstoft J, Køber L, Trøseid M, Kofoed KF, Nielsen SD. Coronary Artery Disease in Persons With Human Immunodeficiency Virus Without Detectable Viral Replication. Open Forum Infect Dis 2023; 10:ofad298. [PMID: 37441354 PMCID: PMC10334377 DOI: 10.1093/ofid/ofad298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Indexed: 07/15/2023] Open
Abstract
Background We aimed to determine the prevalence of coronary artery disease (CAD) in persons with human immunodeficiency virus (HIV; PWH) and investigate whether inflammatory markers, including interleukin 6, IL-1β, and high-sensitivity C-reactive protein (hsCRP), were associated with CAD. Methods From the Copenhagen Comorbidity in HIV Infection (COCOMO) study, we included virologically suppressed PWH who underwent coronary computed tomographic (CT) angiography. Any atherosclerosis was defined as >0% stenosis, and obstructive CAD as ≥50% stenosis. Results Among 669 participants (mean age [standard deviation], 51 [11] years; 89% male), 300 (45%) had atherosclerosis, and 119 (18%) had obstructive CAD. The following risk factors were associated with any atherosclerosis and with obstructive CAD: age, male sex, hypertension, diabetes, smoking, dyslipidemia, time with HIV, and current protease inhibitor use. Interleukin 6 (IL-6) and hsCRP levels >2 mg/L were associated with any atherosclerosis and with obstructive CAD in univariable analyses but not after adjustment for traditional risk factors. IL-1β was not associated with CAD. Conclusions In a large population of PWH without viral replication, almost half had angiographically verified atherosclerosis. High concentrations of IL-6 and hsCRP were associated with CAD in univariable analyses, but adjustment for cardiovascular risk factors attenuated the association, suggesting that inflammation may mediate the association between traditional risk factors and CAD.
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Affiliation(s)
- Andreas D Knudsen
- Department of Infectious Diseases 8632, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Cardiology, The Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Andreas Fuchs
- Department of Cardiology, The Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Benfield
- Department of Infectious Diseases, Copenhagen University Hospital—Amager and Hvidovre, 2650 Hvidovre
| | - Jan Gerstoft
- Department of Infectious Diseases 8632, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Lars Køber
- Department of Cardiology, The Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Marius Trøseid
- Section of Clinical Immunology and Infectious Diseases, Oslo University Hospital, University of Oslo, Oslo, Norway
| | - Klaus F Kofoed
- Department of Cardiology, The Heart Center, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Radiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Susanne D Nielsen
- Correspondence: Susanne D. Nielsen, MD, DMSc, Viro-immunology Research Unit, Department of Infectious Diseases 8632, Copenhagen University Hospital, Blegdamsvej 9B, DK-2100 Copenhagen, Denmark ()
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24
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Jehn S, Roggel A, Dykun I, Balcer B, Al-Rashid F, Totzeck M, Risse J, Kill C, Rassaf T, Mahabadi AA. Epicardial adipose tissue and obstructive coronary artery disease in acute chest pain: the EPIC-ACS study. EUROPEAN HEART JOURNAL OPEN 2023; 3:oead041. [PMID: 37143611 PMCID: PMC10152391 DOI: 10.1093/ehjopen/oead041] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 03/01/2023] [Accepted: 04/14/2023] [Indexed: 05/06/2023]
Abstract
Aims We tested the hypothesis that epicardial adipose tissue (EAT) quantification improves the prediction of the presence of obstructive coronary artery disease (CAD) in patients presenting with acute chest pain to the emergency department. Methods and results Within this prospective observational cohort study, we included 657 consecutive patients (mean age 58.06 ± 18.04 years, 53% male) presenting to the emergency department with acute chest pain suggestive of acute coronary syndrome between December 2018 and August 2020. Patients with ST-elevation myocardial infarction, haemodynamic instability, or known CAD were excluded. As part of the initial workup, we performed bedside echocardiography for quantification of EAT thickness by a dedicated study physician, blinded to all patient characteristics. Treating physicians remained unaware of the results of the EAT assessment. The primary endpoint was defined as the presence of obstructive CAD, as detected in subsequent invasive coronary angiography. Patients reaching the primary endpoint had significantly more EAT than patients without obstructive CAD (7.90 ± 2.56 mm vs. 3.96 ± 1.91 mm, P < 0.0001). In a multivariable regression analysis, a 1 mm increase in EAT thickness was associated with a nearby two-fold increased odds of the presence of obstructive CAD [1.87 (1.64-2.12), P < 0.0001]. Adding EAT to a multivariable model of the GRACE score, cardiac biomarkers and traditional risk factors significantly improved the area under the receiver operating characteristic curve (0.759-0.901, P < 0.0001). Conclusion Epicardial adipose tissue strongly and independently predicts the presence of obstructive CAD in patients presenting with acute chest pain to the emergency department. Our results suggest that the assessment of EAT may improve diagnostic algorithms of patients with acute chest pain.
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Affiliation(s)
- Stefanie Jehn
- The West German Heart and Vascular Center Essen, Department of Cardiology and Vascular Medicine, University Hospital Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - Anja Roggel
- The West German Heart and Vascular Center Essen, Department of Cardiology and Vascular Medicine, University Hospital Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - Iryna Dykun
- The West German Heart and Vascular Center Essen, Department of Cardiology and Vascular Medicine, University Hospital Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - Bastian Balcer
- The West German Heart and Vascular Center Essen, Department of Cardiology and Vascular Medicine, University Hospital Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - Fadi Al-Rashid
- The West German Heart and Vascular Center Essen, Department of Cardiology and Vascular Medicine, University Hospital Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - Matthias Totzeck
- The West German Heart and Vascular Center Essen, Department of Cardiology and Vascular Medicine, University Hospital Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - Joachim Risse
- Center of Emergency Medicine, University Hospital Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - Clemens Kill
- Center of Emergency Medicine, University Hospital Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - Tienush Rassaf
- The West German Heart and Vascular Center Essen, Department of Cardiology and Vascular Medicine, University Hospital Essen, Hufelandstr. 55, 45147 Essen, Germany
| | - Amir A Mahabadi
- Corresponding author. Tel: +49 (0)201/723 84822, Fax: +49 (0)201/723 5401,
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25
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Schillaci M, Marchetti D, Andreini D. In search of new gatekeepers: coronary CT (Computed Tomography) in acute coronary syndrome. Eur Heart J Suppl 2023; 25:B1-B6. [PMID: 37091644 PMCID: PMC10120979 DOI: 10.1093/eurheartjsupp/suad076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2023]
Abstract
Coronary computed tomography (CCT) is a non-invasive imaging method that allows visualization of the epicardial coronary arteries. The diagnostic and prognostic role of CCT has been demonstrated by various randomized trials to such an extent that it has been included as a Class I, level of evidence B recommendation in the latest European Society of Cardiology (ESC) guidelines for the diagnosis of chronic coronary syndrome in patients at intermediate-low cardiovascular risk. In addition to the anatomical evaluation, the CCT allows to evaluate the presence of high-risk characteristics of the atherosclerotic plaque (napkin-ring sign, positive remodelling, spotty calcification, and low-attenuation plaque), thus discriminating the stability of the atheromatous pathology. Furthermore, among the potential of cardiac CT in the emergency department, the possibility of making a triple rule-out must be underlined, excluding three potential big killers as the cause of acute chest pain: acute coronary syndrome, pulmonary embolism, and aortic dissection. Various randomized clinical studies have demonstrated that the prognosis of the patient with chronic coronary artery disease (CAD) improves only if a haemodynamically significant stenosis is treated, generally investigated with invasive fractional flow reserve (FFR); CCT technological advances have made it possible to create an algorithm for calculating the FFR-CT, an index of haemodynamic significance of coronary stenosis, whose correlation with the invasive FFR data and, consequently, with the prognosis has been demonstrated of patients with CAD.
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Affiliation(s)
- Matteo Schillaci
- IRCCS Galeazzi Sant'Ambrogio Hospital, UOC University Cardiology, Milan
| | - Davide Marchetti
- IRCCS Galeazzi Sant'Ambrogio Hospital, UOC University Cardiology, Milan
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26
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Ashburn NP, Snavely AC, O’Neill JC, Allen BR, Christenson RH, Madsen T, Massoomi MR, McCord JK, Mumma BE, Nowak R, Stopyra JP, in’t Veld MH, Wilkerson RG, Mahler SA. Performance of the European Society of Cardiology 0/1-Hour Algorithm With High-Sensitivity Cardiac Troponin T Among Patients With Known Coronary Artery Disease. JAMA Cardiol 2023; 8:347-356. [PMID: 36857071 PMCID: PMC9979014 DOI: 10.1001/jamacardio.2023.0031] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 12/29/2022] [Indexed: 03/02/2023]
Abstract
Importance The European Society of Cardiology (ESC) 0/1-hour algorithm is a validated high-sensitivity cardiac troponin (hs-cTn) protocol for emergency department patients with possible acute coronary syndrome. However, limited data exist regarding its performance in patients with known coronary artery disease (CAD; prior myocardial infarction [MI], coronary revascularization, or ≥70% coronary stenosis). Objective To evaluate and compare the diagnostic performance of the ESC 0/1-hour algorithm for 30-day cardiac death or MI among patients with and without known CAD and determine if the algorithm could achieve the negative predictive value rule-out threshold of 99% or higher. Design, Setting, and Participants This was a preplanned subgroup analysis of the STOP-CP prospective multisite cohort study, which was conducted from January 25, 2017, through September 6, 2018, at 8 emergency departments in the US. Patients 21 years or older with symptoms suggestive of acute coronary syndrome without ST-segment elevation on initial electrocardiogram were included. Analysis took place between February and December 2022. Interventions/Exposures Participants with 0- and 1-hour high-sensitivity cardiac troponin T (hs-cTnT) measures were stratified into rule-out, observation, and rule-in zones using the ESC 0/1-hour hs-cTnT algorithm. Main Outcomes and Measures Cardiac death or MI at 30 days determined by expert adjudicators. Results During the study period, 1430 patients were accrued. In the cohort, 775 individuals (54.2%) were male, 826 (57.8%) were White, and the mean (SD) age was 57.6 (12.8) years. At 30 days, cardiac death or MI occurred in 183 participants (12.8%). Known CAD was present in 449 (31.4%). Among patients with known CAD, the ESC 0/1-hour algorithm classified 178 of 449 (39.6%) into the rule-out zone compared with 648 of 981 (66.1%) without CAD (P < .001). Among rule-out zone patients, 30-day cardiac death or MI occurred in 6 of 178 patients (3.4%) with known CAD and 7 of 648 (1.1%) without CAD (P < .001). The negative predictive value for 30-day cardiac death or MI was 96.6% (95% CI, 92.8-98.8) among patients with known CAD and 98.9% (95% CI, 97.8-99.6) in patients without known CAD (P = .04). Conclusions and Relevance Among patients with known CAD, the ESC 0/1-hour hs-cTnT algorithm was unable to safely exclude 30-day cardiac death or MI. This suggests that clinicians should be cautious if using the algorithm in patients with known CAD. The negative predictive value was significantly higher in patients without a history of CAD but remained less than 99%.
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Affiliation(s)
- Nicklaus P. Ashburn
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Section on Cardiovascular Medicine, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Anna C. Snavely
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - James C. O’Neill
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Brandon R. Allen
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville
| | | | - Troy Madsen
- Department of Emergency Medicine, University of Utah School of Medicine, Salt Lake City
| | - Michael R. Massoomi
- Department of Cardiology, University of Florida College of Medicine, Gainesville
| | - James K. McCord
- Department of Cardiology, Henry Ford Health System, Detroit, Michigan
| | - Bryn E. Mumma
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento
| | - Richard Nowak
- Department of Emergency Medicine, Henry Ford Health System, Detroit, Michigan
| | - Jason P. Stopyra
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Maite Huis in’t Veld
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore
| | - R. Gentry Wilkerson
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore
| | - Simon A. Mahler
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Department of Implementation Science, Wake Forest School of Medicine, Winston-Salem, North Carolina
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27
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Coronary CTA for Acute Chest Pain in the Emergency Department: Comparison of 64-Detector Row Single-Source and Third-Generation Dual-Source Scanners. AJR Am J Roentgenol 2023:1-11. [PMID: 36856300 DOI: 10.2214/ajr.22.28963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
Background: When performing coronary CTA in the emergency department (ED), a contemporary scanner with improved temporal resolution may eliminate the need to administer beta blockers for heart rate (HR) control, thereby expediting workup. Objective: To compare ED length-of-stay (LOS), image quality, frequency of nondiagnostic examinations, and other clinical outcomes between patients undergoing coronary CTA in the ED by a single-source CT (SSCT) scanner with HR control versus a dual-source CT (DSCT) scanner without HR control. Methods: This retrospective study included 509 patients (mean age, 52.1±15.1 years; 283 men, 226 women) at low-to-intermediate risk for acute coronary syndrome who underwent coronary CTA for acute chest pain during off hours in a single ED from March 1, 2020 to April 25, 2022. A total of 205 patients initially underwent CTA using a 64-detector SSCT with HR control (oral beta-blocker administration if HR was >65 beats per minute); following scanner replacement on April 26, 2021, 304 patients underwent CTA using a third-generation DSCT without HR control. Groups were compared in terms of ED LOS and CT completion time (time from ordering of CTA to completion of acquisition) using propensity score matching, and additional endpoints including image quality and nondiagnostic examinations based on radiology reports. Results: DSCT group, compared with SSCT group, showed no significant difference in median ED LOS (505 vs 457 minutes; P=.37), but shorter median CT completion time (95 vs 117 minutes; P<.001); based on mediation analysis, 89% of reduction in CT completion time for DSCT was attributed to absence of HR control. DSCT group, compared with SSCT group, showed higher frequency of examinations with good or excellent image quality (87.8% vs 60.0%, P<.001) and lower frequency of nondiagnostic examinations (1.6% vs 6.3%, P=.01), but no significant difference in frequencies of emergent cardiology consultation, invasive angiography, ED disposition, or coronary revascularization (all P>.05). No patient in either group experienced 30-day all-cause mortality or major adverse cardiovascular event. Conclusion: Use of a DSCT scanner for coronary CTA can eliminate need for beta-blocker administration for HR control while decreasing nondiagnostic examinations. Clinical Impact: A DSCT scanner can expedite clinical processes in the ED.
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28
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Pattereth N, Chaliyadan S, Mathew R, Kumar S, Das CJ, Aggarwal P, Jamshed N. The Role of Triple Rule-out CT in an Indian Emergency Setting. Indian J Crit Care Med 2023; 27:190-194. [PMID: 36960114 PMCID: PMC10028717 DOI: 10.5005/jp-journals-10071-24423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 02/15/2023] [Indexed: 03/05/2023] Open
Abstract
Background Emergency physicians are acutely aware of the consequences of missing fatal diagnoses for acute non-traumatic chest pain and subjecting patients to over-testing. In the large arsenal of tests that are available to us, a triple rule-out computed tomography (TRO-CT) Angiography is often less pursued, due to concerns about their efficacy and safety or because of nescience. We aim to find the yield of the test in an Indian emergency setting and impart some knowledge about it along the way. Materials and methods Twenty-six patients who presented to the emergency department of our institute with acute chest pain, with non-specific electrocardiogram (ECG) findings and negative serial troponin I, underwent TRO-CT. HEART scores of all patients, calculated at their presentation, were correlated with TRO-CT findings. Results Triple rule-out computed tomography angiography was positive in 5 patients (20%), of which 4 cases (16%) were diagnosed to have significant coronary artery disease and one had an acute pulmonary embolism. All 4 patients who had significant coronary artery disease (CAD) diagnosed by TRO-CT had a HEART score of intermediate risk. The mean effective radiation dose of the entire TRO study was 19.024 ± 3.319 mSv (range = 13.89-25.95 mSv). Conclusion Triple rule-out CT angiography is a useful tool in the evaluation of patients presenting with acute chest pain in the emergency and can be an important adjunct in ruling out significant CAD in intermediate-risk patients. Emergency physicians and young residents need to know about this tool in their armamentarium to tackle doubtful cases. How to cite this article Pattereth N, Chaliyadan S, Mathew R, Kumar S, Das CJ, Aggarwal P. et al. The Role of Triple Rule-out CT in an Indian Emergency Setting. Indian J Crit Care Med 2023;27(3):190-194.
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Affiliation(s)
- Navaneeth Pattereth
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Shafneed Chaliyadan
- Department of Surgery, Jan Swasthya Sahyog, Bilaspur, Chhattisgarh, India
- Shafneed Chaliyadan, Department of Surgery, Jan Swasthya Sahyog, Bilaspur, Chhattisgarh, India, Phone: +91 9560819324, e-mail:
| | - Roshan Mathew
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjeev Kumar
- Department of Cardio-radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Chandan J Das
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Praveen Aggarwal
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Nayer Jamshed
- Department of Emergency Medicine, All India Institute of Medical Sciences, New Delhi, India
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29
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Qasum M, Massalha S, Marcusohn E, Elias A, Darawshi S, Zukermann R. Coronary computed tomography angiography in the evaluation of acute chest pain in patients with elevated high sensitive cardiac troponin I (hs-cTn) level. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2023; 27:100276. [PMID: 38511099 PMCID: PMC10945961 DOI: 10.1016/j.ahjo.2023.100276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 02/13/2023] [Accepted: 02/13/2023] [Indexed: 03/22/2024]
Abstract
Aims CCTA is a well-established and safe imaging modality for the diagnosis of CAD and is gate keeping for invasive coronary angiography (ICA). We aimed to examine CCTA performance in patients presenting with ACP and dynamic hs-cTn elevation compatible with MI but not exceeding 7 folds of the URL. We also examined the performance of GRACE and PTP consortium scores in this population of patients.
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Affiliation(s)
- Majd Qasum
- Departments of Cardiology, Rambam Health Care Campus, Haifa, Israel
- Department of Nuclear Medicine, Rambam Health Care Campus, Haifa, Israel
| | - Samia Massalha
- Departments of Cardiology, Rambam Health Care Campus, Haifa, Israel
- Department of Nuclear Medicine, Rambam Health Care Campus, Haifa, Israel
| | - Erez Marcusohn
- Departments of Cardiology, Rambam Health Care Campus, Haifa, Israel
| | - Adi Elias
- Departments of Cardiology, Rambam Health Care Campus, Haifa, Israel
| | - Said Darawshi
- Department of Medicine D, Ruth & Bruce Rappaport Faculty of Medicine, Rambam Health Care Campus, Technion-IIT, Haifa, Israel
| | - Robert Zukermann
- Departments of Cardiology, Rambam Health Care Campus, Haifa, Israel
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30
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Ihdayhid AR, Lan NSR, Figtree GA, Patel S, Arnott C, Hamilton-Craig C, Psaltis PJ, Leipsic J, Fairbairn T, Wahi S, Hillis GS, Rankin JM, Dwivedi G, Nicholls SJ. Contemporary Chest Pain Evaluation: The Australian Case for Cardiac CT. Heart Lung Circ 2023; 32:297-306. [PMID: 36610819 DOI: 10.1016/j.hlc.2022.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 10/07/2022] [Accepted: 12/06/2022] [Indexed: 01/07/2023]
Abstract
Computed tomography coronary angiography (CTCA) is a non-invasive diagnostic modality that provides a comprehensive anatomical assessment of the coronary arteries and coronary atherosclerosis, including plaque burden, composition and morphology. The past decade has witnessed an increase in the role of CTCA for evaluating patients with both stable and acute chest pain, and recent international guidelines have provided increasing support for a first line CTCA diagnostic strategy in select patients. CTCA offers some advantages over current functional tests in the detection of obstructive and non-obstructive coronary artery disease, as well as for ruling out obstructive coronary artery disease. Recent randomised trials have also shown that CTCA improves prognostication and guides the use of guideline-directed preventive therapies, leading to improved clinical outcomes. CTCA technology advances such as fractional flow reserve, plaque quantification and perivascular fat inflammation potentially allow for more personalised risk assessment and targeted therapies. Further studies evaluating demand, supply, and cost-effectiveness of CTCA for evaluating chest pain are required in Australia. This discussion paper revisits the evidence supporting the use of CTCA, provides an overview of its implications and limitations, and considers its potential role for chest pain evaluation pathways in Australia.
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Affiliation(s)
- Abdul Rahman Ihdayhid
- Department of Cardiology, Fiona Stanley Hospital, Perth, WA, Australia; Harry Perkins Institute of Medical Research, Curtin University, Perth, WA, Australia.
| | - Nick S R Lan
- Department of Cardiology, Fiona Stanley Hospital, Perth, WA, Australia; Harry Perkins Institute of Medical Research, University of Western Australia, Perth, WA, Australia
| | - Gemma A Figtree
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Sanjay Patel
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Clare Arnott
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Cardiovascular Division, The George Institute for Global Health, Sydney, NSW, Australia
| | | | - Peter J Psaltis
- Department of Cardiology, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, SA, Australia
| | - Jonathon Leipsic
- University of British Columbia, St Paul's Hospital, Vancouver, Canada
| | | | - Sudhir Wahi
- Princess Alexandra Hospital, University of Queensland, Brisbane, Qld, Australia
| | - Graham S Hillis
- Department of Cardiology and University of Western Australia, Royal Perth Hospital, Perth, WA, Australia
| | - James M Rankin
- Department of Cardiology, Fiona Stanley Hospital, Perth, WA, Australia
| | - Girish Dwivedi
- Department of Cardiology, Fiona Stanley Hospital, Perth, WA, Australia; Harry Perkins Institute of Medical Research, University of Western Australia, Perth, WA, Australia
| | - Stephen J Nicholls
- Monash Cardiovascular Research Centre, Victorian Heart Institute, Monash University, Melbourne, Vic, Australia
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Maroules CD, Rybicki FJ, Ghoshhajra BB, Batlle JC, Branch K, Chinnaiyan K, Hamilton-Craig C, Hoffmann U, Litt H, Meyersohn N, Shaw LJ, Villines TC, Cury RC. 2022 use of coronary computed tomographic angiography for patients presenting with acute chest pain to the emergency department: An expert consensus document of the Society of cardiovascular computed tomography (SCCT): Endorsed by the American College of Radiology (ACR) and North American Society for cardiovascular Imaging (NASCI). J Cardiovasc Comput Tomogr 2023; 17:146-163. [PMID: 36253281 DOI: 10.1016/j.jcct.2022.09.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 09/12/2022] [Accepted: 09/13/2022] [Indexed: 11/22/2022]
Abstract
Coronary computed tomography angiography (CTA) improves the quality of care for patients presenting with acute chest pain (ACP) to the emergency department (ED), particularly in patients with low to intermediate likelihood of acute coronary syndrome (ACS). The Society of Cardiovascular Computed Tomography Guidelines Committee was formed to develop recommendations for acquiring, interpreting, and reporting of coronary CTA to ensure appropriate, safe, and efficient use of this modality. Because of the increasing use of coronary CTA testing for the evaluation of ACP patients, the Committee has been charged with the development of the present document to assist physicians and technologists. These recommendations were produced as an educational tool for practitioners evaluating acute chest pain patients in the ED, in the interest of developing systematic standards of practice for coronary CTA based on the best available data or broad expert consensus. Due to the highly variable nature of medical care, approaches to patient selection, preparation, protocol selection, interpretation or reporting that differs from these guidelines may represent an appropriate variation based on a legitimate assessment of an individual patient's needs.
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Affiliation(s)
| | - Frank J Rybicki
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Brian B Ghoshhajra
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Juan C Batlle
- Department of Radiology, Baptist Cardiac and Vascular Institute, Miami, FL, USA
| | - Kelley Branch
- Department of Cardiology, University of Washington School of Medicine, Seattle, WA, USA
| | | | | | - Udo Hoffmann
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Harold Litt
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - Nandini Meyersohn
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | | | - Todd C Villines
- Department of Cardiology, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Ricardo C Cury
- Department of Radiology, Baptist Cardiac and Vascular Institute, Miami, FL, USA
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32
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Thokala P, Goodacre S, Oatey K, O'Brien R, Newby DE, Gray A. Cost-effectiveness of rapid assessment of potential ischaemic heart disease with CT coronary angiography. Heart 2023; 109:464-469. [PMID: 36702543 DOI: 10.1136/heartjnl-2022-321211] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 10/25/2022] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVES To estimate the cost-effectiveness of early CT coronary angiography (CTCA) for intermediate risk patients with suspected acute coronary syndrome (ACS), compared with standard care METHODS: We performed within-trial economic analysis using data from the RAPID-CTCA randomised trial, and long-term modelling of cost-effectiveness using secondary data sources to estimate the cost-effectiveness of early CTCA compared with standard care for patients with suspected ACS attending acute hospitals in the UK. Cost-effectiveness was estimated as the incremental cost per quality-adjusted life year (QALY) gained, and the probability of each strategy being cost-effective at varying willingness-to-pay per QALY gained. RESULTS The within-trial analysis showed that there were no demonstrable differences in costs or QALYs between early CTCA and standard care, with point estimates suggesting higher costs (£7414 vs £6845: mean difference £569, 95% CI -£208 to £1335; p=0.1521) and lower QALYs (0.749 vs 0.758, mean difference -0.009, 95% CI -0.026 to 0.010; p=0.377) in the CTCA arm. The long-term economic analysis suggested that, on average, CTCA was slightly less effective than standard care alone with 0.025 quality-adjusted life years lost per patient treated and was more expensive with additional costs of £481 per patient treated. At a threshold of £20 000 per QALY, CTCA has 24% probability of being cost-effective. CONCLUSIONS There are no demonstrable differences in within-trial costs and QALYs, and long-term cost-effectiveness modelling suggested higher long-term costs with CTCA and uncertain effect on long-term QALYs, making routine use of CTCA for suspected ACS unlikely to be a cost-effective use of NHS resources.
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Affiliation(s)
- Praveen Thokala
- ScHARR, The University of Sheffield, Sheffield, South Yorkshire, UK
| | - Steve Goodacre
- ScHARR, The University of Sheffield, Sheffield, South Yorkshire, UK
| | - Katherine Oatey
- Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, UK
| | - Rachel O'Brien
- Emergency Medicine Research Group (EMERGE), Emergency Department, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - David E Newby
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Alasdair Gray
- Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, UK.,Emergency Medicine Research Group (EMERGE), Emergency Department, Royal Infirmary of Edinburgh, Edinburgh, UK
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33
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Pareek M, Kragholm KH, Kristensen AMD, Vaduganathan M, Pallisgaard JL, Byrne C, Biering-Sørensen T, Lee CJY, Bonde AN, Mortensen MB, Maeng M, Fosbøl EL, Køber L, Olsen NT, Gislason GH, Bhatt DL, Torp-Pedersen C. Serial troponin-T and long-term outcomes in suspected acute coronary syndrome. Eur Heart J 2023; 44:502-512. [PMID: 36329643 DOI: 10.1093/eurheartj/ehac629] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 09/11/2022] [Accepted: 10/24/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Long-term prognostic implications of serial high-sensitivity troponin concentrations in subjects with suspected acute coronary syndrome are unknown. METHODS AND RESULTS Individuals with a first diagnosis of myocardial infarction, unstable angina, observation for suspected myocardial infarction, or chest pain from 2012 through 2019 who underwent two high-sensitivity troponin-T (hsTnT) measurements 1-7 h apart were identified through Danish national registries. Absolute and relative risks for death at days 0-30 and 31-365, stratified for whether subjects had normal or elevated hsTnT concentrations, and whether these concentrations changed by <20%, > 20 to 50%, or >50% in either direction from first to second measurement, were calculated through multivariable logistic regression with average treatment effect modeling. Of the 28 902 individuals included, 2.8% had died at 30 days, whereas 4.9% of those who had survived the first 30 days died between days 31-365. The standardized risk of death was highest among subjects with two elevated hsTnT concentrations (0-30 days: 4.3%, 31-365 days: 7.2%). In this group, mortality was significantly higher in those with a > 20 to 50% or >50% rise from first to second measurement, though only at 30 days. The risk of death was very low in subjects with two normal hsTnT concentrations (0-30 days: 0.1%, 31-365 days: 0.9%) and did not depend on relative or absolute changes between measurements. CONCLUSIONS Individuals with suspected acute coronary syndrome and two consecutively elevated hsTnT concentrations consistently had the highest risk of death. Mortality was very low in subjects with two normal hsTnT concentrations, irrespective of changes between measurements.
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Affiliation(s)
- Manan Pareek
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Gentofte Hospitalsvej 4, 2900 Hellerup, Denmark.,Department of Cardiology, Copenhagen University Hospital - North Zealand Hospital, Dyrehavevej 29, 3400 Hillerød, Denmark.,Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, 75 Francis St, 02115 Boston, MA, USA
| | - Kristian H Kragholm
- Department of Cardiology, Aalborg University Hospital, Hobrovej 18-22, 9000 Aalborg, Denmark
| | - Anna Meta Dyrvig Kristensen
- Department of Cardiology, Copenhagen University Hospital - North Zealand Hospital, Dyrehavevej 29, 3400 Hillerød, Denmark
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, 75 Francis St, 02115 Boston, MA, USA
| | - Jannik L Pallisgaard
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Gentofte Hospitalsvej 4, 2900 Hellerup, Denmark
| | - Christina Byrne
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Gentofte Hospitalsvej 4, 2900 Hellerup, Denmark.,Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Tor Biering-Sørensen
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Gentofte Hospitalsvej 4, 2900 Hellerup, Denmark.,Institute of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, 2200 Copenhagen, Denmark
| | - Christina Ji-Young Lee
- Department of Cardiology, Aalborg University Hospital, Hobrovej 18-22, 9000 Aalborg, Denmark
| | - Anders Nissen Bonde
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Gentofte Hospitalsvej 4, 2900 Hellerup, Denmark
| | - Martin Bødtker Mortensen
- Department of Cardiology, Aarhus University Hospital, Skejby, Palle Juul-Jensens Boulevard 99, 8200 Aarhus, Denmark
| | - Michael Maeng
- Department of Cardiology, Aarhus University Hospital, Skejby, Palle Juul-Jensens Boulevard 99, 8200 Aarhus, Denmark
| | - Emil L Fosbøl
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Lars Køber
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Niels Thue Olsen
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Gentofte Hospitalsvej 4, 2900 Hellerup, Denmark
| | - Gunnar H Gislason
- Department of Cardiology, Copenhagen University Hospital - Herlev and Gentofte, Gentofte Hospitalsvej 4, 2900 Hellerup, Denmark
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, 75 Francis St, 02115 Boston, MA, USA
| | - Christian Torp-Pedersen
- Department of Cardiology, Copenhagen University Hospital - North Zealand Hospital, Dyrehavevej 29, 3400 Hillerød, Denmark.,Department of Cardiology, Aalborg University Hospital, Hobrovej 18-22, 9000 Aalborg, Denmark
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AI Evaluation of Stenosis on Coronary CTA, Comparison With Quantitative Coronary Angiography and Fractional Flow Reserve: A CREDENCE Trial Substudy. JACC Cardiovasc Imaging 2023; 16:193-205. [PMID: 35183478 DOI: 10.1016/j.jcmg.2021.10.020] [Citation(s) in RCA: 49] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 10/18/2021] [Accepted: 10/22/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Clinical reads of coronary computed tomography angiography (CTA), especially by less experienced readers, may result in overestimation of coronary artery disease stenosis severity compared with expert interpretation. Artificial intelligence (AI)-based solutions applied to coronary CTA may overcome these limitations. OBJECTIVES This study compared the performance for detection and grading of coronary stenoses using artificial intelligence-enabled quantitative coronary computed tomography (AI-QCT) angiography analyses to core lab-interpreted coronary CTA, core lab quantitative coronary angiography (QCA), and invasive fractional flow reserve (FFR). METHODS Coronary CTA, FFR, and QCA data from 303 stable patients (64 ± 10 years of age, 71% male) from the CREDENCE (Computed TomogRaphic Evaluation of Atherosclerotic DEtermiNants of Myocardial IsChEmia) trial were retrospectively analyzed using an Food and Drug Administration-cleared cloud-based software that performs AI-enabled coronary segmentation, lumen and vessel wall determination, plaque quantification and characterization, and stenosis determination. RESULTS Disease prevalence was high, with 32.0%, 35.0%, 21.0%, and 13.0% demonstrating ≥50% stenosis in 0, 1, 2, and 3 coronary vessel territories, respectively. Average AI-QCT analysis time was 10.3 ± 2.7 minutes. AI-QCT evaluation demonstrated per-patient sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 94%, 68%, 81%, 90%, and 84%, respectively, for ≥50% stenosis, and of 94%, 82%, 69%, 97%, and 86%, respectively, for detection of ≥70% stenosis. There was high correlation between stenosis detected on AI-QCT evaluation vs QCA on a per-vessel and per-patient basis (intraclass correlation coefficient = 0.73 and 0.73, respectively; P < 0.001 for both). False positive AI-QCT findings were noted in in 62 of 848 (7.3%) vessels (stenosis of ≥70% by AI-QCT and QCA of <70%); however, 41 (66.1%) of these had an FFR of <0.8. CONCLUSIONS A novel AI-based evaluation of coronary CTA enables rapid and accurate identification and exclusion of high-grade stenosis and with close agreement to blinded, core lab-interpreted quantitative coronary angiography. (Computed TomogRaphic Evaluation of Atherosclerotic DEtermiNants of Myocardial IsChEmia [CREDENCE]; NCT02173275).
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Kolossváry M, Raghu VK, Nagurney JT, Hoffmann U, Lu MT. Deep Learning Analysis of Chest Radiographs to Triage Patients with Acute Chest Pain Syndrome. Radiology 2023; 306:e221926. [PMID: 36648346 PMCID: PMC9885341 DOI: 10.1148/radiol.221926] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 10/23/2022] [Accepted: 11/14/2022] [Indexed: 01/18/2023]
Abstract
Background Patients presenting to the emergency department (ED) with acute chest pain (ACP) syndrome undergo additional testing to exclude acute coronary syndrome (ACS), pulmonary embolism (PE), or aortic dissection (AD), often yielding negative results. Purpose To assess whether deep learning (DL) analysis of the initial chest radiograph may help triage patients with ACP syndrome more efficiently. Materials and Methods This retrospective study used electronic health records of patients with ACP syndrome at presentation who underwent a combination of chest radiography and additional cardiovascular or pulmonary imaging or stress tests at two hospitals (Massachusetts General Hospital [MGH], Brigham and Women's Hospital [BWH]) between January 2005 and December 2015. A DL model was trained on 23 005 patients from MGH to predict a 30-day composite end point of ACS, PE, AD, and all-cause mortality based on chest radiographs. Area under the receiver operating characteristic curve (AUC) was used to compare performance between models (model 1: age + sex; model 2: model 1 + conventional troponin or d-dimer positivity; model 3: model 2 + DL predictions) in internal and external test sets from MGH and BWH, respectively. Results At MGH, 5750 patients (mean age, 59 years ± 17 [SD]; 3329 men, 2421 women) were evaluated. Model 3, which included DL predictions, significantly improved discrimination of those with the composite outcome compared with models 2 and 1 (AUC, 0.85 [95% CI: 0.84, 0.86] vs 0.76 [95% CI: 0.74, 0.77] vs 0.62 [95% CI: 0.60 0.64], respectively; P < .001 for all). When using a sensitivity threshold of 99%, 14% (813 of 5750) of patients could be deferred from cardiovascular or pulmonary testing for differential diagnosis of ACP syndrome using model 3 compared with 2% (98 of 5750) of patients using model 2 (P < .001). Model 3 maintained its diagnostic performance in different age, sex, race, and ethnicity groups. In external validation at BWH (22 764 patients; mean age, 57 years ± 17; 11 470 women), trends were similar and improved after fine tuning. Conclusion Deep learning analysis of chest radiographs may facilitate more efficient triage of patients with acute chest pain syndrome in the emergency department. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Goo in this issue.
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Affiliation(s)
- Márton Kolossváry
- From the Cardiovascular Imaging Research Center (M.K., V.K.R.,
M.T.L.) and Department of Emergency Medicine (J.T.N.), Massachusetts General
Hospital, Harvard Medical School, 165 Cambridge St, Suite 400, Boston, MA 02114;
Gottsegen National Cardiovascular Center, Budapest, Hungary (M.K.);
Physiological Controls Research Center, University Research and Innovation
Center, Óbuda University, Budapest, Hungary (M.K.); and Cleerly Health,
Denver, Colo (U.H.)
| | - Vineet K. Raghu
- From the Cardiovascular Imaging Research Center (M.K., V.K.R.,
M.T.L.) and Department of Emergency Medicine (J.T.N.), Massachusetts General
Hospital, Harvard Medical School, 165 Cambridge St, Suite 400, Boston, MA 02114;
Gottsegen National Cardiovascular Center, Budapest, Hungary (M.K.);
Physiological Controls Research Center, University Research and Innovation
Center, Óbuda University, Budapest, Hungary (M.K.); and Cleerly Health,
Denver, Colo (U.H.)
| | - John T. Nagurney
- From the Cardiovascular Imaging Research Center (M.K., V.K.R.,
M.T.L.) and Department of Emergency Medicine (J.T.N.), Massachusetts General
Hospital, Harvard Medical School, 165 Cambridge St, Suite 400, Boston, MA 02114;
Gottsegen National Cardiovascular Center, Budapest, Hungary (M.K.);
Physiological Controls Research Center, University Research and Innovation
Center, Óbuda University, Budapest, Hungary (M.K.); and Cleerly Health,
Denver, Colo (U.H.)
| | - Udo Hoffmann
- From the Cardiovascular Imaging Research Center (M.K., V.K.R.,
M.T.L.) and Department of Emergency Medicine (J.T.N.), Massachusetts General
Hospital, Harvard Medical School, 165 Cambridge St, Suite 400, Boston, MA 02114;
Gottsegen National Cardiovascular Center, Budapest, Hungary (M.K.);
Physiological Controls Research Center, University Research and Innovation
Center, Óbuda University, Budapest, Hungary (M.K.); and Cleerly Health,
Denver, Colo (U.H.)
| | - Michael T. Lu
- From the Cardiovascular Imaging Research Center (M.K., V.K.R.,
M.T.L.) and Department of Emergency Medicine (J.T.N.), Massachusetts General
Hospital, Harvard Medical School, 165 Cambridge St, Suite 400, Boston, MA 02114;
Gottsegen National Cardiovascular Center, Budapest, Hungary (M.K.);
Physiological Controls Research Center, University Research and Innovation
Center, Óbuda University, Budapest, Hungary (M.K.); and Cleerly Health,
Denver, Colo (U.H.)
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Burch RA, Siddiqui TA, Tou LC, Turner KB, Umair M. The Cost Effectiveness of Coronary CT Angiography and the Effective Utilization of CT-Fractional Flow Reserve in the Diagnosis of Coronary Artery Disease. J Cardiovasc Dev Dis 2023; 10:25. [PMID: 36661920 PMCID: PMC9863924 DOI: 10.3390/jcdd10010025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 12/10/2022] [Accepted: 12/24/2022] [Indexed: 01/11/2023] Open
Abstract
Given the high global disease burden of coronary artery disease (CAD), a major problem facing healthcare economic policy is identifying the most cost-effective diagnostic strategy for patients with suspected CAD. The aim of this review is to assess the long-term cost-effectiveness of coronary computed tomography angiography (CCTA) when compared with other diagnostic modalities and to define the cost and effective diagnostic utilization of computed tomography-fractional flow reserve (CT-FFR). A search was conducted through the MEDLINE database using PubMed with 16 of 119 manuscripts fitting the inclusion and exclusion criteria for review. An analysis of the data included in this review suggests that CCTA is a cost-effective strategy for both low risk acute chest pain patients presenting to the emergency department (ED) and low-to-intermediate risk stable chest pain outpatients. For patients with intermediate-to-high risk, CT-FFR is superior to CCTA in identifying clinically significant stenosis. In low-to-intermediate risk patients, CCTA provides a cost-effective diagnostic strategy with the potential to reduce economic burden and improve long-term health outcomes. CT-FFR should be utilized in intermediate-to-high risk patients with stenosis of uncertain clinical significance. Long-term analysis of cost-effectiveness and diagnostic utility is needed to determine the optimal balance between the cost-effectiveness and diagnostic utility of CT-FFR.
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Affiliation(s)
- Rex A. Burch
- Philadelphia College of Osteopathic Medicine, 625 Old Peachtree Rd NW, Suwanee, GA 30024, USA
| | - Taha A. Siddiqui
- Philadelphia College of Osteopathic Medicine, 625 Old Peachtree Rd NW, Suwanee, GA 30024, USA
| | - Leila C. Tou
- Charles E. Schmidt College of Medicine, Florida Atlantic University, 777 Glades Road BC-71, Boca Raton, FL 33431, USA
| | - Kiera B. Turner
- Charles E. Schmidt College of Medicine, Florida Atlantic University, 777 Glades Road BC-71, Boca Raton, FL 33431, USA
| | - Muhammad Umair
- The Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins Hospital, 601 N Caroline St, Baltimore, MD 21205, USA
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37
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Wang KL, Meah MN, Bularga A, Singh T, Williams MC, Newby DE. Computed tomography coronary angiography in non-ST-segment elevation myocardial infarction. Br J Radiol 2022; 95:20220346. [PMID: 36017975 PMCID: PMC9733606 DOI: 10.1259/bjr.20220346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 07/15/2022] [Accepted: 08/04/2022] [Indexed: 11/05/2022] Open
Abstract
Electrocardiography and high-sensitivity cardiac troponin testing are routinely applied as the initial step for clinical evaluation of patients with suspected non-ST-segment elevation myocardial infarction. Once diagnosed, patients with non-ST-segment elevation myocardial infarction are commenced on antithrombotic and secondary preventative therapies before undergoing invasive coronary angiography to determine the strategy of coronary revascularisation. However, this clinical pathway is imperfect and can lead to challenges in the diagnosis, management, and clinical outcomes of these patients. Computed tomography coronary angiography (CTCA) has increasingly been utilised in the setting of patients with suspected non-ST-segment elevation myocardial infarction, where it has an important role in avoiding unnecessary invasive coronary angiography and reducing downstream non-invasive functional testing for myocardial ischaemia. CTCA is an excellent gatekeeper for the cardiac catheterisation laboratory. In addition, CTCA provides complementary information for patients with myocardial infarction in the absence of obstructive coronary artery disease and highlights alternative or incidental diagnoses for those with cardiac troponin elevation. However, the routine application of CTCA has yet to demonstrate an impact on subsequent major adverse cardiovascular events. There are several ongoing studies evaluating CTCA and its associated technologies that will define and potentially expand its application in patients with suspected or diagnosed non-ST-segment elevation myocardial infarction. We here review the current evidence relating to the clinical application of CTCA in patients with non-ST-segment elevation myocardial infarction and highlight the areas where CTCA is likely to have an increasing important role and impact for our patients.
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Affiliation(s)
| | - Mohammed N Meah
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Anda Bularga
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Trisha Singh
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Michelle C Williams
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - David E Newby
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
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38
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Aziz W, Morgan H, Demir OM, Sinha A, Rua T, Rajani R, Chang AL, Woo E, Mak SM, Benedetti G, Villa A, Preston R, Navin R, O'Kane K, Hunter L, Ismail T, Carr-White G, Beckley-Hoelscher N, Peacock J, Marber M, Razavi R, Perera D. Prospective RandOmised Trial of Emergency Cardiac Computerised Tomography (PROTECCT). Heart 2022; 108:1972-1978. [PMID: 36288924 PMCID: PMC9726962 DOI: 10.1136/heartjnl-2022-320990] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 07/10/2022] [Indexed: 01/18/2023] Open
Abstract
OBJECTIVE Many patients presenting with suspected acute coronary syndrome (ACS) have high-sensitivity cardiac troponin (hs-cTn) concentrations between rule-in and rule-out thresholds and hence need serial testing, which is time consuming. The Prospective RandOmised Trial of Emergency Cardiac Computerised Tomography (PROTECCT) assessed the utility of coronary CT angiography (CCTA) in patients with suspected ACS, non-ischaemic ECG and intermediate initial hs-cTn concentration. METHODS Patients were randomised to CCTA-guided management versus standard of care (SOC). The primary outcome was hospital length of stay (LOS). Secondary outcomes included cost of in-hospital stay and major adverse cardiac events (MACE) at 12 months of follow-up. Data are mean (SD); for LOS harmonic means, IQRs are shown. RESULTS 250 (aged 55 (14) years, 25% women) patients were randomised. Harmonic mean (IQR) LOS was 7.53 (6.0-9.6) hours in the CCTA arm and 8.14 (6.3-9.8) hours in the SOC arm (p=0.13). Inpatient cost was £1285 (£2216) and £1108 (£3573), respectively, p=0.68. LOS was shorter in the CCTA group in patients with <25% stenosis, compared with SOC; 6.6 (5.6-7.8) hours vs 7.5 (6.1-9.4) hours, respectively; p=0.021. More referrals for cardiology outpatient clinic review and cardiac CT-related outpatient referrals occurred in the SOC arm (p=0.01). 12-month MACE rates were similar between the two arms (7 (5.6%) in the CCTA arm and 8 (6.5%) in the SOC arm-log-rank p=0.78). CONCLUSIONS CCTA did not lead to reduced hospital LOS or cost, largely because these outcomes were influenced by the detection of ≥25% grade stenosis in a proportion of patients. TRIAL REGISTRATION NUMBER NCT03583320.
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Affiliation(s)
- Waqar Aziz
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Holly Morgan
- British Heart Foundation Centre of Excellence and NIHR Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King's College London, London, UK
| | - Ozan M Demir
- British Heart Foundation Centre of Excellence and NIHR Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King's College London, London, UK
| | - Aish Sinha
- British Heart Foundation Centre of Excellence and NIHR Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King's College London, London, UK
| | - Tiago Rua
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Ronak Rajani
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Ai-Lee Chang
- Guy's and St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - Eric Woo
- Guy's and St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - Sze Mun Mak
- Guy's and St Thomas' Hospitals NHS Foundation Trust, London, UK
| | | | - Adriana Villa
- Guy's and St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - Rebecca Preston
- Guy's and St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - Roshan Navin
- Guy's and St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - Kevin O'Kane
- Guy's and St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - Laura Hunter
- Guy's and St Thomas' Hospitals NHS Foundation Trust, London, UK
| | - Tevfik Ismail
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | | | | | - Janet Peacock
- Department of Epidemiology, Geisel School of Medicine at Dartmouth, Dartmouth College, Hanover, New Hampshire, USA
| | - Michael Marber
- British Heart Foundation Centre of Excellence and NIHR Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King's College London, London, UK
| | - Reza Razavi
- School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Divaka Perera
- British Heart Foundation Centre of Excellence and NIHR Biomedical Research Centre at the School of Cardiovascular Medicine and Sciences, King's College London, London, UK
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Hitter R, Orlev A, Amsalem I, Levi N, Wolak T, Farkash R, Bogot N, Glikson M, Wolak A. The Added Value of a High CT Coronary Artery Calcium Score in the Management of Patients Presenting with Acute Chest Pain vs. Stable Chest Pain. J Cardiovasc Dev Dis 2022; 9:jcdd9110390. [PMID: 36421925 PMCID: PMC9694127 DOI: 10.3390/jcdd9110390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 11/09/2022] [Accepted: 11/10/2022] [Indexed: 11/16/2022] Open
Abstract
Background: Contrast computerized tomography (CT) scan is occasionally aborted due to a high coronary artery calcium score (CACS). For the same CACS in our clinical practice, we observed a higher occurrence of severe coronary artery disease (CAD) in patients with acute chest pain (ACP) compared to patients with stable chest pain (SCP). Since it is known that ACP differs in many ways from SCP, the aim of this study was to compare the predictive value of a high CACS for the diagnosis of severe CAD between ACP and SCP patients. Methods: This single center observational retrospective study included consecutive patients who underwent cardiac CT for chest pain and were found to have a CACS of >200 Agatston units. Patients were divided into two groups, ACP and SCP. Severe CAD was defined as ≥70% stenosis on coronary CT angiography or invasive coronary angiography. Baseline characteristics and final diagnosis of severe CAD were compared. Results: The cohort included 220 patients, 106 with ACP and 114 with SCP. ACP patients had higher severe CAD rates (60.4% vs. 36.8%; p < 0.001). On multivariate analysis including cardiac risk factors, CACS > 400 au (OR = 2.34 95% CI [1.32−4.15]; p = 0.004) and ACP (OR = 2.54 95% CI [1.45−4.45]; p = 0.001) were independent predictors of severe CAD. The addition of the clinical setting of ACP added significant incremental predictive value for severe stenosis. Conclusion: A high CACS is more associated with severe CAD in patients presenting with ACP than SCP. The findings suggest that the CACS could impact the management of patients during the scan.
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Affiliation(s)
- Rafael Hitter
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112102, Israel
| | - Amir Orlev
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112102, Israel
| | - Itshak Amsalem
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112102, Israel
| | - Nir Levi
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112102, Israel
| | - Talya Wolak
- Department of Internal Medicine, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112102, Israel
| | - Rivka Farkash
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112102, Israel
| | - Naama Bogot
- Department of Radiology, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112102, Israel
| | - Michael Glikson
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112102, Israel
| | - Arik Wolak
- Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 9112102, Israel
- Correspondence: ; Tel.: +972-2-6555955; Fax: +972-2-6555437
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40
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Cury RC, Leipsic J, Abbara S, Achenbach S, Berman D, Bittencourt M, Budoff M, Chinnaiyan K, Choi AD, Ghoshhajra B, Jacobs J, Koweek L, Lesser J, Maroules C, Rubin GD, Rybicki FJ, Shaw LJ, Williams MC, Williamson E, White CS, Villines TC, Blankstein R. CAD-RADS™ 2.0 - 2022 Coronary Artery Disease-Reporting and Data System: An Expert Consensus Document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Cardiology (ACC), the American College of Radiology (ACR), and the North America Society of Cardiovascular Imaging (NASCI). JACC Cardiovasc Imaging 2022; 15:1974-2001. [PMID: 36115815 DOI: 10.1016/j.jcmg.2022.07.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 03/10/2022] [Accepted: 07/02/2022] [Indexed: 12/14/2022]
Abstract
Coronary Artery Disease Reporting and Data System (CAD-RADS) was created to standardize reporting system for patients undergoing coronary CT angiography (CCTA) and to guide possible next steps in patient management. The goal of this updated 2022 CAD-RADS 2.0 is to improve the initial reporting system for CCTA by considering new technical developments in cardiac CT, including data from recent clinical trials and new clinical guidelines. The updated CAD-RADS classification will follow an established framework of stenosis, plaque burden, and modifiers, which will include assessment of lesion-specific ischemia using CT fractional-flow-reserve (CT-FFR) or myocardial CT perfusion (CTP), when performed. Similar to the method used in the original CAD-RADS version, the determinant for stenosis severity classification will be the most severe coronary artery luminal stenosis on a per-patient basis, ranging from CAD-RADS 0 (zero) for absence of any plaque or stenosis to CAD-RADS 5 indicating the presence of at least one totally occluded coronary artery. Given the increasing data supporting the prognostic relevance of coronary plaque burden, this document will provide various methods to estimate and report total plaque burden. The addition of P1 to P4 descriptors are used to denote increasing categories of plaque burden. The main goal of CAD-RADS, which should always be interpreted together with the impression found in the report, remains to facilitate communication of test results with referring physicians along with suggestions for subsequent patient management. In addition, CAD-RADS will continue to provide a framework of standardization that may benefit education, research, peer-review, artificial intelligence development, clinical trial design, population health and quality assurance with the ultimate goal of improving patient care.
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Affiliation(s)
- Ricardo C Cury
- Miami Cardiac and Vascular Institute and Baptist Health of South Florida, Miami, Florida, USA.
| | - Jonathon Leipsic
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada
| | - Suhny Abbara
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Stephan Achenbach
- Friedrich-Alexander-Universität, Department of Cardiology, Erlangen, Germany
| | - Daniel Berman
- Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Marcio Bittencourt
- Division of Cardiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Matthew Budoff
- David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | | | - Andrew D Choi
- The George Washington University School of Medicine, Washington, DC, USA
| | - Brian Ghoshhajra
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jill Jacobs
- NYU Langone Medical Center, New York, New York, USA
| | - Lynne Koweek
- Department of Radiology, Duke University, Durham, North Carolina, USA
| | - John Lesser
- Division of Cardiology, Minneapolis Heart Institute, Minneapolis, Minnesota, USA
| | | | - Geoffrey D Rubin
- Department of Medical Imaging, University of Arizona, Tucson, Arizona, USA
| | - Frank J Rybicki
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Leslee J Shaw
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Eric Williamson
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Todd C Villines
- Division of Cardiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Ron Blankstein
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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41
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Is Coronary Plaque Quantification More Important Than Stenosis Detection in Patients With Acute Coronary Syndrome? JACC Cardiovasc Imaging 2022; 15:1926-1928. [PMID: 36357134 DOI: 10.1016/j.jcmg.2022.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Revised: 05/27/2022] [Accepted: 05/31/2022] [Indexed: 12/14/2022]
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42
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Cury RC, Leipsic J, Abbara S, Achenbach S, Berman D, Bittencourt M, Budoff M, Chinnaiyan K, Choi AD, Ghoshhajra B, Jacobs J, Koweek L, Lesser J, Maroules C, Rubin GD, Rybicki FJ, Shaw LJ, Williams MC, Williamson E, White CS, Villines TC, Blankstein R. CAD-RADS™ 2.0 - 2022 Coronary Artery Disease - Reporting and Data System.: An expert consensus document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Cardiology (ACC), the American College of Radiology (ACR) and the North America Society of Cardiovascular Imaging (NASCI). J Am Coll Radiol 2022; 19:1185-1212. [PMID: 36436841 DOI: 10.1016/j.jacr.2022.09.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Coronary Artery Disease Reporting and Data System (CAD-RADS) was created to standardize reporting system for patients undergoing coronary CT angiography (CCTA) and to guide possible next steps in patient management. The goal of this updated 2022 CAD-RADS 2.0 is to improve the initial reporting system for CCTA by considering new technical developments in Cardiac CT, including data from recent clinical trials and new clinical guidelines. The updated CAD-RADS classification will follow an established framework of stenosis, plaque burden, and modifiers, which will include assessment of lesion-specific ischemia using CT fractional-flow-reserve (CT-FFR) or myocardial CT perfusion (CTP), when performed. Similar to the method used in the original CAD-RADS version, the determinant for stenosis severity classification will be the most severe coronary artery luminal stenosis on a per-patient basis, ranging from CAD-RADS 0 (zero) for absence of any plaque or stenosis to CAD-RADS 5 indicating the presence of at least one totally occluded coronary artery. Given the increasing data supporting the prognostic relevance of coronary plaque burden, this document will provide various methods to estimate and report total plaque burden. The addition of P1 to P4 descriptors are used to denote increasing categories of plaque burden. The main goal of CAD-RADS, which should always be interpreted together with the impression found in the report, remains to facilitate communication of test results with referring physicians along with suggestions for subsequent patient management. In addition, CAD-RADS will continue to provide a framework of standardization that may benefit education, research, peer-review, artificial intelligence development, clinical trial design, population health and quality assurance with the ultimate goal of improving patient care.
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Affiliation(s)
- Ricardo C Cury
- Miami Cardiac and Vascular Institute and Baptist Health of South Florida, 8900 N Kendall Drive, Miami FL, 33176, USA.
| | - Jonathon Leipsic
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada
| | - Suhny Abbara
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Stephan Achenbach
- Friedrich-Alexander-Universität, Department of Cardiology, Erlangen, Germany
| | | | | | - Matthew Budoff
- David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | | | - Andrew D Choi
- The George Washington University School of Medicine, Washington, DC, USA
| | - Brian Ghoshhajra
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Jill Jacobs
- NYU Langone Medical Center, New York, NY, USA
| | - Lynne Koweek
- Department of Radiology, Duke University, Durham, NC, USA
| | - John Lesser
- Division of Cardiology, Minneapolis Heart Institute, Minneapolis, MN, USA
| | | | - Geoffrey D Rubin
- Department of Medical Imaging, University of Arizona, Tucson, AZ, USA
| | - Frank J Rybicki
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Leslee J Shaw
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | - Todd C Villines
- Division of Cardiology, University of Virginia Health System, Charlottesville, VA, USA
| | - Ron Blankstein
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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43
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Cury RC, Leipsic J, Abbara S, Achenbach S, Berman D, Bittencourt M, Budoff M, Chinnaiyan K, Choi AD, Ghoshhajra B, Jacobs J, Koweek L, Lesser J, Maroules C, Rubin GD, Rybicki FJ, Shaw LJ, Williams MC, Williamson E, White CS, Villines TC, Blankstein R. CAD-RADS™ 2.0 - 2022 Coronary Artery Disease-Reporting and Data System: An Expert Consensus Document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Cardiology (ACC), the American College of Radiology (ACR), and the North America Society of Cardiovascular Imaging (NASCI). J Cardiovasc Comput Tomogr 2022; 16:536-557. [PMID: 35864070 DOI: 10.1016/j.jcct.2022.07.002] [Citation(s) in RCA: 82] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 03/10/2022] [Accepted: 07/02/2022] [Indexed: 12/14/2022]
Abstract
Coronary Artery Disease Reporting and Data System (CAD-RADS) was created to standardize reporting system for patients undergoing coronary CT angiography (CCTA) and to guide possible next steps in patient management. The goal of this updated 2022 CAD-RADS 2.0 is to improve the initial reporting system for CCTA by considering new technical developments in Cardiac CT, including data from recent clinical trials and new clinical guidelines. The updated CAD-RADS classification will follow an established framework of stenosis, plaque burden, and modifiers, which will include assessment of lesion-specific ischemia using CT fractional-flow-reserve (CT-FFR) or myocardial CT perfusion (CTP), when performed. Similar to the method used in the original CAD-RADS version, the determinant for stenosis severity classification will be the most severe coronary artery luminal stenosis on a per-patient basis, ranging from CAD-RADS 0 (zero) for absence of any plaque or stenosis to CAD-RADS 5 indicating the presence of at least one totally occluded coronary artery. Given the increasing data supporting the prognostic relevance of coronary plaque burden, this document will provide various methods to estimate and report total plaque burden. The addition of P1 to P4 descriptors are used to denote increasing categories of plaque burden. The main goal of CAD-RADS, which should always be interpreted together with the impression found in the report, remains to facilitate communication of test results with referring physicians along with suggestions for subsequent patient management. In addition, CAD-RADS will continue to provide a framework of standardization that may benefit education, research, peer-review, artificial intelligence development, clinical trial design, population health and quality assurance with the ultimate goal of improving patient care.
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Affiliation(s)
- Ricardo C Cury
- Miami Cardiac and Vascular Institute and Baptist Health of South Florida, Miami FL, USA.
| | - Jonathon Leipsic
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada
| | - Suhny Abbara
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Stephan Achenbach
- Friedrich-Alexander-Universität, Department of Cardiology, Erlangen, Germany
| | | | | | - Matthew Budoff
- David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | | | - Andrew D Choi
- The George Washington University School of Medicine, Washington, DC, USA
| | - Brian Ghoshhajra
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Jill Jacobs
- NYU Langone Medical Center, New York, NY, USA
| | - Lynne Koweek
- Department of Radiology, Duke University, Durham, NC, USA
| | - John Lesser
- Division of Cardiology, Minneapolis Heart Institute, Minneapolis, MN, USA
| | | | - Geoffrey D Rubin
- Department of Medical Imaging, University of Arizona, Tucson, AZ, USA
| | - Frank J Rybicki
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Leslee J Shaw
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | - Todd C Villines
- Division of Cardiology, University of Virginia Health System, Charlottesville, VA, USA
| | - Ron Blankstein
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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44
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Dahal S, Budoff MJ, Roy SK. Coronary Computed Tomography Angiography for Evaluation of Chest Pain in the Emergency Department. Tex Heart Inst J 2022; 49:e217550. [PMID: 36511943 PMCID: PMC9809099 DOI: 10.14503/thij-21-7550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Coronary computed tomography angiography has emerged as an important diagnostic modality for evaluation of acute chest pain in the emergency department for patients at low to intermediate risk for acute coronary syndromes. Several clinical trials have shown excellent negative predictive value of coronary computed tomography angiography to detect obstructive coronary artery disease. Cardiac biomarkers such as troponins and creatine kinase MB, along with history, electrocardiogram, age, risk factors, troponin score, and Thrombolysis in Myocardial Infarction score should be used in conjunction with coronary computed tomography angiography for safe and rapid discharge of patients from the emergency department. Coronary computed tomography angiography along with high-sensitivity troponin assays could be effective for rapid evaluation of acute chest pain in the emergency department, but high-sensitivity troponins are not always available. Emergency department physicians are not quite comfortable making clinical decisions, especially if the coronary stenosis is in the range of 50% to 70%. In these cases, further evaluation with functional testing, such as nuclear stress testing or stress echocardiogram, is a common approach in many centers; however, newer methods such as fractional flow reserve computed tomography could be safely incorporated in coronary computed tomography angiography to help with clinical decision-making in these scenarios.
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Affiliation(s)
- Suraj Dahal
- Department of Cardiology, Virginia Commonwealth University, Richmond, Virginia
| | - Matthew J. Budoff
- Department of Cardiology, Harbor-UCLA Medical Center, Torrance, California
| | - Sion K. Roy
- Department of Cardiology, Harbor-UCLA Medical Center, Torrance, California
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45
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Kaur G, Chand S, Rai D, Baibhav B, Blankstein R, Mukherjee D, Levy P, Gulati M. Contemporary Risk Stratification of Acute Coronary Syndrome. US CARDIOLOGY REVIEW 2022. [DOI: 10.15420/usc.2022.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Chest pain is one of the most common presenting concerns of patients seeking care in the emergency department, and the underlying etiology can range from acute coronary syndrome to various other non-cardiac causes. Initial evaluation should focus on characterizing symptoms and identifying risk factors, but further risk stratification using clinical decision pathways and biomarkers (cardiac troponin) is essential. The 2021 American Heart Association/American College of Cardiology guidelines for the evaluation and diagnosis of chest pain represent the first ever guidelines for the evaluation of patients with acute chest pain. The contemporary risk stratification methods described in these guidelines allow for the identification of patient subgroups: patients who do not require further testing, patients who should proceed directly to the cath lab, and patients who will benefit from further anatomic or functional testing. In this review, we describe contemporary risk stratification methods for acute coronary syndrome and summarize the recommendations put forth by the guidelines.
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Affiliation(s)
- Gurleen Kaur
- Department of Internal Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Swati Chand
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY
| | - Devesh Rai
- Department of Cardiology, Sands-Constellation Heart Institute, Rochester Regional Health, Rochester, NY
| | - Bipul Baibhav
- Department of Cardiology, Sands-Constellation Heart Institute, Rochester Regional Health, Rochester, NY
| | - Ron Blankstein
- Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA
| | - Debabrata Mukherjee
- Division of Cardiovascular Diseases, Texas Tech University Health Sciences Center at El Paso, El Paso, TX
| | - Phillip Levy
- Department of Emergency Medicine, Wayne State University, Detroit, MI
| | - Martha Gulati
- Department of Cardiology, Barbra Streisand Women’s Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA
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46
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Cury RC, Leipsic J, Abbara S, Achenbach S, Berman D, Bittencourt M, Budoff M, Chinnaiyan K, Choi AD, Ghoshhajra B, Jacobs J, Koweek L, Lesser J, Maroules C, Rubin GD, Rybicki FJ, Shaw LJ, Williams MC, Williamson E, White CS, Villines TC, Blankstein R. CAD-RADS™ 2.0 - 2022 Coronary Artery Disease - Reporting and Data System An Expert Consensus Document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Cardiology (ACC), the American College of Radiology (ACR) and the North America Society of Cardiovascular Imaging (NASCI). Radiol Cardiothorac Imaging 2022; 4:e220183. [PMID: 36339062 PMCID: PMC9627235 DOI: 10.1148/ryct.220183] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 03/10/2022] [Accepted: 07/02/2022] [Indexed: 06/16/2023]
Abstract
Coronary Artery Disease Reporting and Data System (CAD-RADS) was created to standardize reporting system for patients undergoing coronary CT angiography (CCTA) and to guide possible next steps in patient management. The goal of this updated 2022 CAD-RADS 2.0 is to improve the initial reporting system for CCTA by considering new technical developments in Cardiac CT, including data from recent clinical trials and new clinical guidelines. The updated CAD-RADS classification will follow an established framework of stenosis, plaque burden, and modifiers, which will include assessment of lesion-specific ischemia using CT fractional-flow-reserve (CT-FFR) or myocardial CT perfusion (CTP), when performed. Similar to the method used in the original CAD-RADS version, the determinant for stenosis severity classification will be the most severe coronary artery luminal stenosis on a per-patient basis, ranging from CAD-RADS 0 (zero) for absence of any plaque or stenosis to CAD-RADS 5 indicating the presence of at least one totally occluded coronary artery. Given the increasing data supporting the prognostic relevance of coronary plaque burden, this document will provide various methods to estimate and report total plaque burden. The addition of P1 to P4 descriptors are used to denote increasing categories of plaque burden. The main goal of CAD-RADS, which should always be interpreted together with the impression found in the report, remains to facilitate communication of test results with referring physicians along with suggestions for subsequent patient management. In addition, CAD-RADS will continue to provide a framework of standardization that may benefit education, research, peer-review, artificial intelligence development, clinical trial design, population health and quality assurance with the ultimate goal of improving patient care. Keywords: Coronary Artery Disease, Coronary CTA, CAD-RADS, Reporting and Data System, Stenosis Severity, Report Standardization Terminology, Plaque Burden, Ischemia Supplemental material is available for this article. This article is published synchronously in Radiology: Cardiothoracic Imaging, Journal of Cardiovascular Computed Tomography, JACC: Cardiovascular Imaging, Journal of the American College of Radiology, and International Journal for Cardiovascular Imaging. © 2022 Society of Cardiovascular Computed Tomography. Published by RSNA with permission.
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Affiliation(s)
- Ricardo C. Cury
- Miami Cardiac and Vascular Institute and Baptist Health of South
Florida, 8900 N Kendall Drive, Miami FL, 33176, USA
| | | | - Suhny Abbara
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX,
USA
| | - Stephan Achenbach
- Friedrich-Alexander-Universität, Department of Cardiology,
Ulmenweg 18, 90154, Erlangen, Germany
| | | | | | | | | | - Andrew D. Choi
- The George Washington University School of Medicine, USA
| | | | - Jill Jacobs
- NYU Langone Medical Center, 550 First Avenue, New York, NY, 10016,
USA
| | | | - John Lesser
- Division of Cardiology, Minneapolis Heart Institute, USA
| | | | | | - Frank J. Rybicki
- Department of Radiology, University of Cincinnati College of
Medicine, USA
| | | | | | | | | | - Todd C. Villines
- Division of Cardiology, University of Virginia Health System,
USA
| | - Ron Blankstein
- Brigham and Women's Hospital, Harvard Medical School,
USA
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47
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Leonardi S, Montalto C, Carrara G, Casella G, Grosseto D, Galazzi M, Repetto A, Tua L, Portolan M, Ottani F, Galvani M, Gentile L, Cardelli LS, De Servi S, Antonelli A, De Ferrari GM, Visconti LO, Campo G. Clinical governance of patients with acute coronary syndromes. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:797-805. [PMID: 36124872 PMCID: PMC9709629 DOI: 10.1093/ehjacc/zuac106] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/16/2022] [Accepted: 08/29/2022] [Indexed: 01/06/2023]
Abstract
AIMS Using the principles of clinical governance, a patient-centred approach intended to promote holistic quality improvement, we designed a prospective, multicentre study in patients with acute coronary syndrome (ACS). We aimed to verify and quantify consecutive inclusion and describe relative and absolute effects of indicators of quality for diagnosis and therapy. METHODS AND RESULTS Administrative codes for invasive coronary angiography and acute myocardial infarction were used to estimate the ACS universe. The ratio between the number of patients included and the estimated ACS universe was the consecutive index. Co-primary quality indicators were timely reperfusion in patients admitted with ST-elevation ACS and optimal medical therapy at discharge. Cox-proportional hazard models for 1-year death with admission and discharge-specific covariates quantified relative risk reductions and adjusted number needed to treat (NNT) absolute risk reductions. Hospital codes tested had a 99.5% sensitivity to identify ACS universe. We estimated that 7344 (95% CI: 6852-7867) ACS patients were admitted and 5107 were enrolled-i.e. a consecutive index of 69.6% (95% CI 64.9-74.5%), which varied from 30.7 to 79.2% across sites. Timely reperfusion was achieved in 22.4% (95% CI: 20.7-24.1%) of patients, was associated with an adjusted hazard ratio (HR) for 1-year death of 0.60 (95% CI: 0.40-0.89) and an adjusted NNT of 65 (95% CI: 44-250). Corresponding values for optimal medical therapy were 70.1% (95% CI: 68.7-71.4%), HR of 0.50 (95% CI: 0.38-0.66), and NNT of 98 (95% CI: 79-145). CONCLUSION A comprehensive approach to quality for patients with ACS may promote equitable access of care and inform implementation of health care delivery. REGISTRATION ClinicalTrials.Gov ID NCT04255537.
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Affiliation(s)
| | - Claudio Montalto
- Department of Molecular Medicine, University of Pavia, Pavia 27100, Italy
| | | | | | | | - Marco Galazzi
- Department of Molecular Medicine, University of Pavia, Pavia 27100, Italy
| | | | - Lorenzo Tua
- Department of Molecular Medicine, University of Pavia, Pavia 27100, Italy
| | | | - Filippo Ottani
- U.O.C. Cardiologia, Ospedale G.B. Morgagni, Forlì—Fondazione Cardiologica ‘Myriam Zito Sacco’, Forlì, Italy
| | - Marcello Galvani
- U.O.C. Cardiologia, Ospedale G.B. Morgagni, Forlì—Fondazione Cardiologica ‘Myriam Zito Sacco’, Forlì, Italy
| | | | - Laura Sofia Cardelli
- Cardiology Unit, Azienda Ospedaliera Universitaria di Ferrara, Cona, Italy,Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Stefano De Servi
- IRCCS MultiMedica, Milan, Italy,University of Pavia Medical School, Pavia, Italy
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48
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Meng H, Ruan J, Yan Z, Chen Y, Liu J, Li X, Meng F. New Progress in Early Diagnosis of Atherosclerosis. Int J Mol Sci 2022; 23:ijms23168939. [PMID: 36012202 PMCID: PMC9409135 DOI: 10.3390/ijms23168939] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 07/30/2022] [Accepted: 08/06/2022] [Indexed: 11/18/2022] Open
Abstract
Coronary atherosclerosis is a potentially chronic circulatory condition that endangers human health. The biological cause underpinning cardiovascular disease is coronary atherosclerosis, and acute cardiovascular events can develop due to thrombosis, platelet aggregation, and unstable atherosclerotic plaque rupture. Coronary atherosclerosis is progressive, and three specific changes appear, with fat spots and stripes, atherosclerosis and thin-walled fiber atherosclerosis, and then complex changes in arteries. The progression and severity of cardiovascular disease are correlated with various levels of calcium accumulation in the coronary artery. The therapy and diagnosis of coronary atherosclerosis benefit from the initial assessment of the size and degree of calcification. This article will discuss the new progress in the early diagnosis of coronary atherosclerosis in terms of three aspects: imaging, gene and protein markers, and trace elements. This study intends to present the latest methods for diagnosing patients with early atherosclerosis through a literature review.
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Affiliation(s)
- Heyu Meng
- Jilin Provincial Precision Medicine Key Laboratory for Cardiovascular Genetic Diagnosis, Jilin Provincial Cardiovascular Research Institute, Jilin University, Changchun 130033, China
- Jilin Provincial Engineering Laboratory for Endothelial Function and Genetic Diagnosis of Cardiovascular Disease, Jilin Provincial Cardiovascular Research Institute, Jilin University, Changchun 130033, China
- Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Jilin Provincial Cardiovascular Research Institute, Jilin University, Changchun 130033, China
| | - Jianjun Ruan
- Jilin Provincial Precision Medicine Key Laboratory for Cardiovascular Genetic Diagnosis, Jilin Provincial Cardiovascular Research Institute, Jilin University, Changchun 130033, China
- Jilin Provincial Engineering Laboratory for Endothelial Function and Genetic Diagnosis of Cardiovascular Disease, Jilin Provincial Cardiovascular Research Institute, Jilin University, Changchun 130033, China
- Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Jilin Provincial Cardiovascular Research Institute, Jilin University, Changchun 130033, China
| | - Zhaohan Yan
- Jilin Provincial Precision Medicine Key Laboratory for Cardiovascular Genetic Diagnosis, Jilin Provincial Cardiovascular Research Institute, Jilin University, Changchun 130033, China
- Jilin Provincial Engineering Laboratory for Endothelial Function and Genetic Diagnosis of Cardiovascular Disease, Jilin Provincial Cardiovascular Research Institute, Jilin University, Changchun 130033, China
- Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Jilin Provincial Cardiovascular Research Institute, Jilin University, Changchun 130033, China
| | - Yanqiu Chen
- Jilin Provincial Precision Medicine Key Laboratory for Cardiovascular Genetic Diagnosis, Jilin Provincial Cardiovascular Research Institute, Jilin University, Changchun 130033, China
- Jilin Provincial Engineering Laboratory for Endothelial Function and Genetic Diagnosis of Cardiovascular Disease, Jilin Provincial Cardiovascular Research Institute, Jilin University, Changchun 130033, China
- Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Jilin Provincial Cardiovascular Research Institute, Jilin University, Changchun 130033, China
| | - Jinsha Liu
- Jilin Provincial Precision Medicine Key Laboratory for Cardiovascular Genetic Diagnosis, Jilin Provincial Cardiovascular Research Institute, Jilin University, Changchun 130033, China
- Jilin Provincial Engineering Laboratory for Endothelial Function and Genetic Diagnosis of Cardiovascular Disease, Jilin Provincial Cardiovascular Research Institute, Jilin University, Changchun 130033, China
- Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Jilin Provincial Cardiovascular Research Institute, Jilin University, Changchun 130033, China
| | - Xiangdong Li
- Jilin Provincial Precision Medicine Key Laboratory for Cardiovascular Genetic Diagnosis, Jilin Provincial Cardiovascular Research Institute, Jilin University, Changchun 130033, China
- Jilin Provincial Engineering Laboratory for Endothelial Function and Genetic Diagnosis of Cardiovascular Disease, Jilin Provincial Cardiovascular Research Institute, Jilin University, Changchun 130033, China
- Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Jilin Provincial Cardiovascular Research Institute, Jilin University, Changchun 130033, China
| | - Fanbo Meng
- Jilin Provincial Precision Medicine Key Laboratory for Cardiovascular Genetic Diagnosis, Jilin Provincial Cardiovascular Research Institute, Jilin University, Changchun 130033, China
- Jilin Provincial Engineering Laboratory for Endothelial Function and Genetic Diagnosis of Cardiovascular Disease, Jilin Provincial Cardiovascular Research Institute, Jilin University, Changchun 130033, China
- Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Jilin Provincial Cardiovascular Research Institute, Jilin University, Changchun 130033, China
- Correspondence: ; Tel.: +86-15948346855
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49
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Gray AJ, Roobottom C, Smith JE, Goodacre S, Oatey K, O'Brien R, Storey RF, Curzen N, Keating L, Kardos A, Felmeden D, Lee RJ, Thokala P, Lewis SC, Newby DE. Early computed tomography coronary angiography in adults presenting with suspected acute coronary syndrome: the RAPID-CTCA RCT. Health Technol Assess 2022; 26:1-114. [PMID: 36062819 DOI: 10.3310/irwi5180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Acute coronary syndrome is a common medical emergency. The optimal strategy to investigate patients who are at intermediate risk of acute coronary syndrome has not been fully determined. OBJECTIVE To investigate the role of early computed tomography coronary angiography in the investigation and treatment of adults presenting with suspected acute coronary syndrome. DESIGN A prospective, multicentre, open, parallel-group randomised controlled trial with blinded end-point adjudication. SETTING Thirty-seven hospitals in the UK. PARTICIPANTS Adults (aged ≥ 18 years) presenting to the emergency department, acute medicine services or cardiology department with suspected or provisionally diagnosed acute coronary syndrome and at least one of the following: (1) a prior history of coronary artery disease, (2) a cardiac troponin level > 99th centile and (3) an abnormal 12-lead electrocardiogram. INTERVENTIONS Early computed tomography coronary angiography in addition to standard care was compared with standard care alone. Participants were followed up for 1 year. MAIN OUTCOME MEASURE One-year all-cause death or subsequent type 1 (spontaneous) or type 4b (stent thrombosis) myocardial infarction, measured as the time to such event adjudicated by two cardiologists blinded to the computerised tomography coronary angiography ( CTCA ) arm. Cost-effectiveness was estimated as the lifetime incremental cost per quality-adjusted life-year gained. RESULTS Between 23 March 2015 and 27 June 2019, 1748 participants [mean age 62 years (standard deviation 13 years), 64% male, mean Global Registry Of Acute Coronary Events score 115 (standard deviation 35)] were randomised to receive early computed tomography coronary angiography (n = 877) or standard care alone (n = 871). The primary end point occurred in 51 (5.8%) participants randomised to receive computed tomography coronary angiography and 53 (6.1%) participants randomised to receive standard care (adjusted hazard ratio 0.91, 95% confidence interval 0.62 to 1.35; p = 0.65). Computed tomography coronary angiography was associated with a reduced use of invasive coronary angiography (adjusted hazard ratio 0.81, 95% confidence interval 0.72 to 0.92; p = 0.001) but no change in coronary revascularisation (adjusted hazard ratio 1.03, 95% confidence interval 0.87 to 1.21; p = 0.76), acute coronary syndrome therapies (adjusted odds ratio 1.06, 95% confidence interval 0.85 to 1.32; p = 0.63) or preventative therapies on discharge (adjusted odds ratio 1.07, 95% confidence interval 0.87 to 1.32; p = 0.52). Early computed tomography coronary angiography was associated with longer hospitalisations (median increase 0.21 days, 95% confidence interval 0.05 to 0.40 days) and higher mean total health-care costs over 1 year (£561 more per patient) than standard care. LIMITATIONS The principal limitation of the trial was the slower than anticipated recruitment, leading to a revised sample size, and the requirement to compromise and accept a larger relative effect size estimate for the trial intervention. FUTURE WORK The potential role of computed tomography coronary angiography in selected patients with a low probability of obstructive coronary artery disease (intermediate or mildly elevated level of troponin) or who have limited access to invasive cardiac catheterisation facilities needs further prospective evaluation. CONCLUSIONS In patients with suspected or provisionally diagnosed acute coronary syndrome, computed tomography coronary angiography did not alter overall coronary therapeutic interventions or 1-year clinical outcomes, but it did increase the length of hospital stay and health-care costs. These findings do not support the routine use of early computed tomography coronary angiography in intermediate-risk patients with acute chest pain. TRIAL REGISTRATION This trial is registered as ISRCTN19102565 and Clinical Trials NCT02284191. FUNDING This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 37. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Alasdair J Gray
- Usher Institute, University of Edinburgh, Edinburgh, UK.,Department of Emergency Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Carl Roobottom
- Department of Radiology, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Jason E Smith
- Emergency Department, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Steve Goodacre
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Katherine Oatey
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Rachel O'Brien
- Department of Emergency Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
| | - Nick Curzen
- Faculty of Medicine, University of Southampton and Coronary Research Group, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Liza Keating
- Department of Emergency Medicine, Royal Berkshire NHS Foundation Trust, Reading, UK
| | - Attila Kardos
- Department of Cardiology, Milton Keynes University Hospital NHS Foundation Trust, Milton Keynes, UK
| | - Dirk Felmeden
- Department of Cardiology, Torbay and South Devon NHS Foundation Trust, Torquay, UK
| | - Robert J Lee
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Praveen Thokala
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Steff C Lewis
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - David E Newby
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK.,Department of Cardiology, Royal Infirmary of Edinburgh, Edinburgh, UK
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50
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Wang KL, Roobottom C, Smith JE, Goodacre S, Oatey K, O’Brien R, Storey RF, Curzen N, Keating L, Kardos A, Felmeden D, Thokala P, Mills NL, Newby DE, Gray AJ. Presentation cardiac troponin and early computed tomography coronary angiography in patients with suspected acute coronary syndrome: a pre-specified secondary analysis of the RAPID-CTCA trial. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:570-579. [PMID: 35642464 PMCID: PMC9302931 DOI: 10.1093/ehjacc/zuac057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 05/06/2022] [Accepted: 05/09/2022] [Indexed: 12/28/2022]
Abstract
Aims To evaluate the potential associations between presentation cardiac troponin and the clinical impact of early computed tomography coronary angiography (CTCA) in intermediate-risk patients with suspected acute coronary syndrome. Methods and results In a large multicentre randomized controlled trial of patients with intermediate-risk chest pain due to suspected acute coronary syndrome, early CTCA had no effect on the primary outcome—death or subsequent Type 1 or 4b myocardial infarction—but reduced the rate of invasive coronary angiography. In this pre-specified secondary analysis, cardiovascular testing and clinical outcomes were compared between those with or without cardiac troponin elevation at presentation. Of 1748 patients, 1004 (57%) had an elevated cardiac troponin concentration and 744 (43%) had a normal concentration. Patients with cardiac troponin elevation had a higher Global Registry of Acute Coronary Events score (132 vs. 91; P < 0.001) and were more likely to have obstructive coronary artery disease (59 vs. 33%; P < 0.001), non-invasive (72 vs. 52%; P < 0.001) and invasive (72 vs. 38%; P < 0.001) testing, coronary revascularization (47 vs. 15%; P < 0.001), and the primary outcome (8 vs. 3%; P = 0.007) at 1 year. However, there was no evidence that presentation cardiac troponin was associated with the relative effects of early CTCA on rates of non-invasive (Pinteraction = 0.33) and invasive (Pinteraction = 0.99) testing, coronary revascularization (Pinteraction = 0.57), or the primary outcome (Pinteraction = 0.41). Conclusion Presentation cardiac troponin had no demonstrable associations between the effects of early CTCA on reductions in non-invasive and invasive testing, or the lack of effect on coronary revascularization or the primary outcome in intermediate-risk patients with suspected acute coronary syndrome.
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Affiliation(s)
- Kang Ling Wang
- Centre for Cardiovascular Science, University of Edinburgh , Chancellor’s Building, 49 Little France Crescent, Edinburgh EH16 4SB , UK
- School of Medicine, National Yang Ming Chiao Tung University , Taipei , Taiwan
- General Clinical Research Center, Taipei Veterans General Hospital , Taipei , Taiwan
| | - Carl Roobottom
- Department of Radiology, University Hospitals Plymouth NHS Trust , Plymouth , UK
| | - Jason E Smith
- Emergency Department, University Hospitals Plymouth NHS Trust , Plymouth , UK
| | - Steve Goodacre
- School of Health and Related Research, University of Sheffield , Sheffield , UK
| | - Katherine Oatey
- Edinburgh Clinical Trials Unit, University of Edinburgh , Edinburgh , UK
| | - Rachel O’Brien
- Department of Emergency Medicine, Royal Infirmary of Edinburgh , Edinburgh , UK
| | - Robert F Storey
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield , Sheffield , UK
| | - Nick Curzen
- Faculty of Medicine, University of Southampton , Southampton , UK
- Department of Cardiology, University Hospital Southampton NHS Foundation Trust , Southampton , UK
| | - Liza Keating
- Department of Emergency Medicine, Royal Berkshire NHS Foundation Trust , Reading , UK
| | - Attila Kardos
- Translational Cardiovascular Research Group, Milton Keynes University Hospital NHS Foundation Trust , Milton Keynes , UK
- Faculty of Medicine and Health Science, University of Buckingham , Buckingham , UK
| | - Dirk Felmeden
- Department of Cardiology, Torbay and South Devon NHS Foundation Trust , Torquay , UK
| | - Praveen Thokala
- School of Health and Related Research, University of Sheffield , Sheffield , UK
| | - Nicholas L Mills
- Centre for Cardiovascular Science, University of Edinburgh , Chancellor’s Building, 49 Little France Crescent, Edinburgh EH16 4SB , UK
- Usher Institute, University of Edinburgh , Edinburgh , UK
| | - David E Newby
- Centre for Cardiovascular Science, University of Edinburgh , Chancellor’s Building, 49 Little France Crescent, Edinburgh EH16 4SB , UK
| | - Alasdair J Gray
- Department of Emergency Medicine, Royal Infirmary of Edinburgh , Edinburgh , UK
- Usher Institute, University of Edinburgh , Edinburgh , UK
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