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Gray AJ, Oatey K, Grahamslaw J, Irvine S, Cafferkey J, Kennel T, Norrie J, Walsh T, Lone N, Horner D, Appelboam A, Hall P, Skipworth RJE, Bell D, Rooney K, Shankar-Hari M, Corfield AR. Albumin Versus Balanced Crystalloid for the Early Resuscitation of Sepsis: An Open Parallel-Group Randomized Feasibility Trial. The ABC-Sepsis Trial. Crit Care Med 2024:00003246-990000000-00348. [PMID: 38912884 DOI: 10.1097/ccm.0000000000006348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/25/2024]
Abstract
OBJECTIVES International guidelines recommend IV crystalloid as the primary fluid for sepsis resuscitation, with 5% human albumin solution (HAS) as the second line. However, it is unclear which fluid has superior clinical effectiveness. We conducted a trial to assess the feasibility of delivering a randomized controlled trial comparing balanced crystalloid against 5% HAS as sole early resuscitation fluid in patients with sepsis presenting to hospital. DESIGN Multicenter, open, parallel-group randomized feasibility trial. SETTING Emergency departments (EDs) in 15 U.K. National Health Service (NHS) hospitals. PATIENTS Adult patients with sepsis and a National Early Warning Score 2 greater than or equal to five requiring IV fluids withing one hour of randomization. INTERVENTIONS IV fluid resuscitation with balanced crystalloid or 5% HAS for the first 6 hours following randomization. MEASUREMENTS AND MAIN RESULTS Primary feasibility outcomes were recruitment rate and 30-day mortality. We successfully recruited 301 participants over 12 months. Mean (sd) age was 69 years (± 16 yr), and 151 (50%) were male. From 1303 participants screened; 502 participants were potentially eligible and 300 randomized to receive trial intervention with greater than 95% of participants receiving the intervention. The median number of participants per site was 19 (range, 1-63). Thirty-day mortality was 17.9% (n = 53). Thirty-one participants died (21.1%) within 30 days in the 5% HAS arm, compared with 22 participants (14.8%) in the crystalloid arm (adjusted odds ratio, 1.50; 95% CIs, 0.84-2.83). CONCLUSIONS Our results suggest it is feasible to recruit critically ill patients to a fluid resuscitation trial in U.K. EDs using 5% HAS as a primary resuscitation fluid. There was lower mortality in the balanced crystalloid arm. Given these findings, a definitive trial is likely to be deliverable, but the point estimates suggest such a trial would be unlikely to demonstrate a significant benefit from using 5% HAS as a primary resuscitation fluid in sepsis.
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Affiliation(s)
- Alasdair J Gray
- Emergency Medicine Research Group, Emergency Department, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Katherine Oatey
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Julia Grahamslaw
- Emergency Medicine Research Group, Emergency Department, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Sîan Irvine
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - John Cafferkey
- Emergency Medicine Research Group, Emergency Department, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Titouan Kennel
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - John Norrie
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Tim Walsh
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Nazir Lone
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Daniel Horner
- Emergency Department, Salford NHS Foundation Trust, Northern Care Alliance NHS Foundation Trust, Salford, United Kingdom
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, United Kingdom
| | - Andy Appelboam
- Academic Department of Emergency Medicine, Royal Devon University Healthcare NHS Foundation Trust, Exeter, United Kingdom
| | - Peter Hall
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Richard J E Skipworth
- Clinical Surgery, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Derek Bell
- Faculty of Medicine, School of Public Health, University College, London, United Kingdom
| | - Kevin Rooney
- Department of Intensive Care, Royal Alexandra Hospital, Paisley, United Kingdom
- University of Glasgow, Glasgow, United Kingdom
| | - Manu Shankar-Hari
- Institute for Regeneration and Repair, University of Edinburgh, Edinburgh, United Kingdom
| | - Alasdair R Corfield
- University of Glasgow, Glasgow, United Kingdom
- Emergency Department, Royal Alexandra Hospital, Paisley, United Kingdom
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2
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Wang KL, Taggart C, McDermott M, O'Brien R, Oatey K, Keating L, Storey RF, Felmeden D, Curzen N, Kardos A, Roobottom C, Smith J, Goodacre S, Newby DE, Gray AJ. Clinical decision aids and computed tomography coronary angiography in patients with suspected acute coronary syndrome. Emerg Med J 2024:emermed-2024-213904. [PMID: 38857986 DOI: 10.1136/emermed-2024-213904] [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: 01/11/2024] [Accepted: 05/16/2024] [Indexed: 06/12/2024]
Abstract
BACKGROUND The HEART score, the T-MACS model and the GRACE score support early decision-making for acute chest pain, which could be complemented by CT coronary angiography (CTCA). However, their performance has not been directly compared. METHODS In this secondary analysis of a multicentre randomised controlled trial of early CTCA in intermediate-risk patients with suspected acute coronary syndrome, C-statistics and performance metrics (using the predefined cut-offs) of clinical decision aids and CTCA, alone and then in combination, for the index hospital diagnosis of acute coronary syndrome and for 30-day coronary revascularisation were assessed in those who underwent CTCA and had complete data. RESULTS Among 699 patients, 358 (51%) had an index hospital diagnosis of acute coronary syndrome, for which the C-statistic was higher for CTCA (0.80), followed by the T-MACS model (0.78), the HEART score (0.74) and the GRACE score (0.60). The negative predictive value was higher for the absence of coronary artery disease on CTCA (0.90) or a T-MACS estimate of <0.05 (0.83) than a HEART score of <4 (0.81) and a GRACE score of <109 (0.55). For 30-day coronary revascularisation, CTCA had the greatest C-statistic (0.80) with a negative predictive value of 0.96 and 0.92 in the absence of coronary artery disease and obstructive coronary artery disease, respectively. The combination of the T-MACS estimates and the CTCA findings was most discriminative for the index hospital diagnosis of acute coronary syndrome (C-statistic, 0.88) and predictive of 30-day coronary revascularisation (C-statistic, 0.85). No patients with a T-MACS estimate of <0.05 and normal coronary arteries had acute coronary syndrome during index hospitalisation or underwent coronary revascularisation within 30 days. CONCLUSIONS In intermediate-risk patients with suspected acute coronary syndrome, the T-MACS model combined with CTCA improved discrimination of the index hospital diagnosis of acute coronary syndrome and prediction of 30-day coronary revascularisation. TRIAL REGISTRATION NUMBER NCT02284191.
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Affiliation(s)
- Kang-Ling Wang
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
- General Clinical Research Center, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Caelan Taggart
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
- Department of Cardiology, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Michael McDermott
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Rachel O'Brien
- EMERGE (Emergency Medicine Research Group, Edinburgh), Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Katherine Oatey
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Liza Keating
- Department of Emergency Medicine, Royal Berkshire NHS Foundation Trust, Reading, UK
| | - Robert F Storey
- Division of Clinical Medicine, University of Sheffield, Sheffield, UK
- NIHR Sheffield Biomedical Research Centre, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Dirk Felmeden
- Department of Cardiology, Torbay and South Devon NHS Foundation Trust, Torquay, UK
| | - Nick Curzen
- Faculty of Medicine, University of Southampton, Southampton, UK
- Department of Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Attila Kardos
- TCRG (Translational Cardiovascular Research Group), Milton Keynes University Hospital NHS Foundation Trust, Milton Keynes, UK
| | - Carl Roobottom
- Department of Radiology, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Jason Smith
- Emergency Department, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Steve Goodacre
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - David E Newby
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Alasdair J Gray
- EMERGE (Emergency Medicine Research Group, Edinburgh), Royal Infirmary of Edinburgh, Edinburgh, UK
- Usher Institute, University of Edinburgh, Edinburgh, UK
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3
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Becker L, Alonso A, Kruska M, Baumann S, Grassl N, Lesch H, Eisele P, Sieburg T, Behnes M, Schupp T, Kayed H, Platten M, Duerschmied D, Szabo K, Akin I, Fastner C. [Acute ischemic stroke and troponin elevation: update of the Mannheim clinical algorithm]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2024:10.1007/s00108-024-01719-x. [PMID: 38831047 DOI: 10.1007/s00108-024-01719-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/29/2024] [Indexed: 06/05/2024]
Abstract
Elevated high-sensitivity cardiac troponin (hs-cTn) levels should be expected in about half of all patients with acute ischemic stroke (AIS). Since those patients are at risk of increased morbidity and mortality, often attributable to cardiac causes, an adequate work-up of the underlying etiology is required. This can only be achieved by a team of cardiologists and neurologists. Since underlying causes of hs-cTn elevation in AIS patients are diverse, often atypical or silent in their clinical presentation and some, such as an accompanying myocardial infarction, can be acutely life-threatening, the work-up should follow a standardized clinical algorithm. The vast majority of hs-cTn elevations are caused by non-ischemic myocardial injury associated with AIS. This work presents a practice-oriented approach to differential diagnosis with the update of the Mannheim clinical algorithm for acute ischemic stroke and troponin elevation.
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Affiliation(s)
- Louisa Becker
- Neurologische Klinik, Universitätsmedizin Mannheim (UMM) und Mannheim Center for Translational Neurosciences (MCTN), Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Deutschland
| | - Angelika Alonso
- Neurologische Klinik, Universitätsmedizin Mannheim (UMM) und Mannheim Center for Translational Neurosciences (MCTN), Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Deutschland
| | - Mathieu Kruska
- I. Medizinische Klinik, Schwerpunkte: Kardiologie, Angiologie, Hämostaseologie und Internistische Intensivmedizin, Universitätsmedizin Mannheim (UMM), Medizinische Fakultät Mannheim, Universität Heidelberg, European Center for AngioScience (ECAS) und Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Standort Heidelberg/Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - Stefan Baumann
- Innere Medizin II, Abteilung für Kardiologie, Kreiskrankenhaus Bergstraße, Heppenheim, Deutschland
| | - Niklas Grassl
- Neurologische Klinik, Universitätsmedizin Mannheim (UMM) und Mannheim Center for Translational Neurosciences (MCTN), Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Deutschland
| | - Hendrik Lesch
- Neurologische Klinik, Universitätsmedizin Mannheim (UMM) und Mannheim Center for Translational Neurosciences (MCTN), Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Deutschland
| | - Philipp Eisele
- Neurologische Klinik, Universitätsmedizin Mannheim (UMM) und Mannheim Center for Translational Neurosciences (MCTN), Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Deutschland
| | - Tina Sieburg
- I. Medizinische Klinik, Schwerpunkte: Kardiologie, Angiologie, Hämostaseologie und Internistische Intensivmedizin, Universitätsmedizin Mannheim (UMM), Medizinische Fakultät Mannheim, Universität Heidelberg, European Center for AngioScience (ECAS) und Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Standort Heidelberg/Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - Michael Behnes
- I. Medizinische Klinik, Schwerpunkte: Kardiologie, Angiologie, Hämostaseologie und Internistische Intensivmedizin, Universitätsmedizin Mannheim (UMM), Medizinische Fakultät Mannheim, Universität Heidelberg, European Center for AngioScience (ECAS) und Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Standort Heidelberg/Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - Tobias Schupp
- I. Medizinische Klinik, Schwerpunkte: Kardiologie, Angiologie, Hämostaseologie und Internistische Intensivmedizin, Universitätsmedizin Mannheim (UMM), Medizinische Fakultät Mannheim, Universität Heidelberg, European Center for AngioScience (ECAS) und Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Standort Heidelberg/Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - Hany Kayed
- Klinik für Radiologie und Nuklearmedizin, Universitätsmedizin Mannheim (UMM), Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Deutschland
| | - Michael Platten
- Neurologische Klinik, Universitätsmedizin Mannheim (UMM) und Mannheim Center for Translational Neurosciences (MCTN), Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Deutschland
| | - Daniel Duerschmied
- I. Medizinische Klinik, Schwerpunkte: Kardiologie, Angiologie, Hämostaseologie und Internistische Intensivmedizin, Universitätsmedizin Mannheim (UMM), Medizinische Fakultät Mannheim, Universität Heidelberg, European Center for AngioScience (ECAS) und Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Standort Heidelberg/Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - Kristina Szabo
- Neurologische Klinik, Universitätsmedizin Mannheim (UMM) und Mannheim Center for Translational Neurosciences (MCTN), Medizinische Fakultät Mannheim, Universität Heidelberg, Mannheim, Deutschland
| | - Ibrahim Akin
- I. Medizinische Klinik, Schwerpunkte: Kardiologie, Angiologie, Hämostaseologie und Internistische Intensivmedizin, Universitätsmedizin Mannheim (UMM), Medizinische Fakultät Mannheim, Universität Heidelberg, European Center for AngioScience (ECAS) und Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Standort Heidelberg/Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland
| | - Christian Fastner
- I. Medizinische Klinik, Schwerpunkte: Kardiologie, Angiologie, Hämostaseologie und Internistische Intensivmedizin, Universitätsmedizin Mannheim (UMM), Medizinische Fakultät Mannheim, Universität Heidelberg, European Center for AngioScience (ECAS) und Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK), Standort Heidelberg/Mannheim, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Deutschland.
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Zheng YL, Cai PY, Li J, Huang DH, Wang WD, Li MM, Du JR, Wang YG, Cai YL, Zhang RC, Wu CC, Lin S, Lin HL. A novel radiomics-based technique for identifying vulnerable coronary plaques: a follow-up study. Coron Artery Dis 2024:00019501-990000000-00232. [PMID: 38767051 DOI: 10.1097/mca.0000000000001389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
BACKGROUND Previous reports have suggested that coronary computed tomography angiography (CCTA)-based radiomics analysis is a potentially helpful tool for assessing vulnerable plaques. We aimed to investigate whether coronary radiomic analysis of CCTA images could identify vulnerable plaques in patients with stable angina pectoris. METHODS This retrospective study included patients initially diagnosed with stable angina pectoris. Patients were randomly divided into either the training or test dataset at an 8 : 2 ratio. Radiomics features were extracted from CCTA images. Radiomics models for predicting vulnerable plaques were developed using the support vector machine (SVM) algorithm. The model performance was assessed using the area under the curve (AUC); the accuracy, sensitivity, and specificity were calculated to compare the diagnostic performance using the two cohorts. RESULTS A total of 158 patients were included in the analysis. The SVM radiomics model performed well in predicting vulnerable plaques, with AUC values of 0.977 and 0.875 for the training and test cohorts, respectively. With optimal cutoff values, the radiomics model showed accuracies of 0.91 and 0.882 in the training and test cohorts, respectively. CONCLUSION Although further larger population studies are necessary, this novel CCTA radiomics model may identify vulnerable plaques in patients with stable angina pectoris.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Shu Lin
- Centre of Neurological and Metabolic Research, the Second Affiliated Hospital of Fujian Medical University, Quanzhou, China and
- Diabetes and Metabolism Division, Garvan Institute of Medical Research, Sydney, New South Wales, Australia
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5
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Jabbour RJ, Curzen N. How will coronary physiology, plaque vulnerability and ischemia be integrated in future patient pathways with chest pain? Expert Rev Cardiovasc Ther 2024; 22:141-143. [PMID: 38679907 DOI: 10.1080/14779072.2024.2347224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 04/22/2024] [Indexed: 05/01/2024]
Affiliation(s)
- Richard J Jabbour
- Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Faculty of Medicine, University of Southampton, Southampton, UK
| | - Nick Curzen
- Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
- Faculty of Medicine, University of Southampton, Southampton, UK
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6
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Thießen N, Schnabel R. [Diagnosis of acute coronary syndrome]. Dtsch Med Wochenschr 2024; 149:488-495. [PMID: 38621682 DOI: 10.1055/a-2163-2586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
Acute coronary syndrome is one of the most important differential diagnostic considerations in emergency medicine. It describes the constellation of newly occurring clinical symptoms, often accompanied by typical 12-lead ECG changes and the release of cardiac troponins. The spectrum includes unstable angina pectoris, non-ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI). It is important to consistently carry out the diagnostic steps that are crucial for further therapeutic procedures to avoid delaying life-saving invasive coronary diagnostics, without losing sight of the diverse, sometimes time-critical differential diagnoses. Anamnesis and clinical examination form the basis of the further procedure. Further developments of biomarker assays with personalized limit values, new imaging modalities with ever higher resolution and faster imaging methods as well as advances in automated ECG analysis with integration of all findings through artificial intelligence will continue to offer many optimization options in the future diagnosis of acute coronary syndrome.
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7
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Huang SW, Liu YK. Pediatric Chest Pain: A Review of Diagnostic Tools in the Pediatric Emergency Department. Diagnostics (Basel) 2024; 14:526. [PMID: 38473000 DOI: 10.3390/diagnostics14050526] [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: 02/05/2024] [Revised: 02/26/2024] [Accepted: 02/27/2024] [Indexed: 03/14/2024] Open
Abstract
Pediatric chest pain is a common chief complaint in the emergency department. Not surprisingly, children with chest pain are usually brought to the emergency department by their parents out of fear of heart disease. However, chest pain in the pediatric population is generally a benign disease. In this review, we have identified musculoskeletal pain as the most prevalent etiology of chest pain in the pediatric population, accounting for 38.7-86.3% of cases, followed by pulmonary (1.8-12.8%), gastrointestinal (0.3-9.3%), psychogenic (5.1-83.6%), and cardiac chest pain (0.3-8.0%). Various diagnostic procedures are commonly used in the emergency department for cardiac chest pain, including electrocardiogram (ECG), chest radiography, cardiac troponin examination, and echocardiography. However, these examinations demonstrate limited sensitivity in identifying cardiac etiologies, with sensitivities ranging from 0 to 17.8% for ECG and 11.0 to 17.2% for chest radiography. To avoid the overuse of these diagnostic tools, a well-designed standardized algorithm for pediatric chest pain could decrease unnecessary examination without missing severe diseases.
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Affiliation(s)
- Szu-Wei Huang
- Emergency Department, Wan Fang Hospital, Taipei Medical University, Taipei 11695, Taiwan
| | - Ying-Kuo Liu
- Department of Pediatrics, Wan Fang Hospital, Taipei Medical University, Taipei 11695, Taiwan
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8
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Strube T, Lambrakis K, George K, Lehman S, Ali Afzali HH, Chew DP. Could Computed Tomography Coronary Angiography Replace Invasive Coronary Angiography as a First-Line Diagnostic Investigation in Suspected Acute Coronary Syndromes? A Decision-Analytic Model. Heart Lung Circ 2024; 33:342-349. [PMID: 38336541 DOI: 10.1016/j.hlc.2023.12.010] [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: 03/16/2023] [Revised: 09/28/2023] [Accepted: 12/10/2023] [Indexed: 02/12/2024]
Abstract
BACKGROUND The implementation of high-sensitivity cardiac troponin (hs-cTn) assays into clinical practice has resulted in the identification of a novel cohort of patients with modestly increased troponin concentrations. Subsequent increases in rates of coronary angiography have been observed, without significant increases in rates of coronary revascularisation. Computed tomography coronary angiography (CTCA) is a non-invasive investigation that offers the opportunity to decouple investigation from the impetus to revascularise, and may provide an alternative, more risk-appropriate initial investigative strategy for the cohort with low to moderate hs-cTn increases. This analysis seeks to define the threshold of pre-test probability of coronary revascularisation in patients with suspected acute coronary syndrome at which a strategy of initial CTCA is safe and a more cost-effective approach than standard invasive coronary angiography (ICA). METHODS A cost-benefit evaluation was conducted using a decision-analytic model. The primary outcome measure was the incremental cost-effectiveness ratio (ICER) of CTCA in comparison with ICA as an initial diagnostic investigation for patients with hs-cTnT levels between 5 and 100 ng/L. Secondary outcome measures of costs, patient outcomes, and quality-adjusted life years were analysed. RESULTS Median base case ICER over 1,000 trials was $17,163 AUD but demonstrated large variability. Sensitivity analysis demonstrated that CTCA was cost-effective until the probability of requiring revascularisation was ∼60%, beyond which point CTCA was associated with higher costs and poorer outcomes than ICA. CONCLUSIONS Computed tomography coronary angiography may be a cost-effective first-line investigation for patients with moderate hs-cTnT rises until/up to a 60% pre-test probability for receiving coronary revascularisation. To objectively assess the optimal circumstances of cost-effectiveness, prospective evaluation incorporating the estimated probability of revascularisation will be required.
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Affiliation(s)
- Taylor Strube
- South Australian Department of Health, Adelaide, SA, Australia
| | - Kristina Lambrakis
- South Australian Department of Health, Adelaide, SA, Australia; College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | - Kate George
- South Australian Department of Health, Adelaide, SA, Australia
| | - Sam Lehman
- South Australian Department of Health, Adelaide, SA, Australia; College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
| | | | - Derek P Chew
- South Australian Department of Health, Adelaide, SA, Australia; College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia; Victorian Heart Institute, Monash University, Melbourne, Vic, Australia; Victorian Heart Hospital, Monash Health, Melbourne, Vic, Australia.
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9
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Liu J, Li C, Mei W, Qin H. The research progress and research trends in acute coronary syndrome nursing: A review of visual analysis based on the Web of Science database. Medicine (Baltimore) 2024; 103:e35849. [PMID: 38363951 PMCID: PMC10869036 DOI: 10.1097/md.0000000000035849] [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: 07/19/2023] [Accepted: 10/03/2023] [Indexed: 02/18/2024] Open
Abstract
Acute coronary syndrome (ACS) is one of the most common and severe forms of cardiovascular disease and has attracted worldwide attention with increased morbidity and mortality in recent years. There are few review studies in the field of its care in the form of bibliometric studies. We searched the Web of Science Core Collection database for articles and reviews in the area of ACS nursing for visual mapping analysis. Our objectives are to explore the hot topics and frontiers of research in the field of ACS nursing and to identify collaborative relationships between countries, institutions, and authors. This study will provide researchers with intuitive reference data for future in-depth studies of ACSs.
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Affiliation(s)
- Jialong Liu
- School of Nursing, Anhui University of Chinese Medicine, Hefei, China
| | - Chaojun Li
- School of Nursing, Anhui University of Chinese Medicine, Hefei, China
| | - Wanping Mei
- School of Nursing, Anhui University of Chinese Medicine, Hefei, China
| | - Hanzhi Qin
- Department of Nursing, the First Affiliated Hospital of University of Science and Technology of China, Hefei, China
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10
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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: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/24/2023]
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11
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Dewey M, Henriques JPS, Kirov H, Vliegenthart R. ESR Bridges: CT builds bridges in coronary artery disease. Eur Radiol 2024; 34:732-735. [PMID: 38291257 PMCID: PMC10853315 DOI: 10.1007/s00330-023-10485-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Revised: 11/19/2023] [Accepted: 11/23/2023] [Indexed: 02/01/2024]
Affiliation(s)
- Marc Dewey
- Charité-Universitätsmedizin Berlin, corporate member of Department of Radiology, Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany.
- Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Berlin, Germany.
- Berlin University Alliance, Berlin, Germany.
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Deutsches Herzzentrum der Charité (DHZC), Berlin, Germany.
| | - José P S Henriques
- Department of Cardiology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Hristo Kirov
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich Schiller University of Jena, Jena, Germany
| | - Rozemarijn Vliegenthart
- Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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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: 0] [Impact Index Per Article: 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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13
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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: 498] [Impact Index Per Article: 498.0] [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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14
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Mézquita AJV, Biavati F, Falk V, Alkadhi H, Hajhosseiny R, Maurovich-Horvat P, Manka R, Kozerke S, Stuber M, Derlin T, Channon KM, Išgum I, Coenen A, Foellmer B, Dey D, Volleberg RHJA, Meinel FG, Dweck MR, Piek JJ, van de Hoef T, Landmesser U, Guagliumi G, Giannopoulos AA, Botnar RM, Khamis R, Williams MC, Newby DE, Dewey M. Clinical quantitative coronary artery stenosis and coronary atherosclerosis imaging: a Consensus Statement from the Quantitative Cardiovascular Imaging Study Group. Nat Rev Cardiol 2023; 20:696-714. [PMID: 37277608 DOI: 10.1038/s41569-023-00880-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/19/2023] [Indexed: 06/07/2023]
Abstract
The detection and characterization of coronary artery stenosis and atherosclerosis using imaging tools are key for clinical decision-making in patients with known or suspected coronary artery disease. In this regard, imaging-based quantification can be improved by choosing the most appropriate imaging modality for diagnosis, treatment and procedural planning. In this Consensus Statement, we provide clinical consensus recommendations on the optimal use of different imaging techniques in various patient populations and describe the advances in imaging technology. Clinical consensus recommendations on the appropriateness of each imaging technique for direct coronary artery visualization were derived through a three-step, real-time Delphi process that took place before, during and after the Second International Quantitative Cardiovascular Imaging Meeting in September 2022. According to the Delphi survey answers, CT is the method of choice to rule out obstructive stenosis in patients with an intermediate pre-test probability of coronary artery disease and enables quantitative assessment of coronary plaque with respect to dimensions, composition, location and related risk of future cardiovascular events, whereas MRI facilitates the visualization of coronary plaque and can be used in experienced centres as a radiation-free, second-line option for non-invasive coronary angiography. PET has the greatest potential for quantifying inflammation in coronary plaque but SPECT currently has a limited role in clinical coronary artery stenosis and atherosclerosis imaging. Invasive coronary angiography is the reference standard for stenosis assessment but cannot characterize coronary plaques. Finally, intravascular ultrasonography and optical coherence tomography are the most important invasive imaging modalities for the identification of plaques at high risk of rupture. The recommendations made in this Consensus Statement will help clinicians to choose the most appropriate imaging modality on the basis of the specific clinical scenario, individual patient characteristics and the availability of each imaging modality.
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Affiliation(s)
| | - Federico Biavati
- Department of Radiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité (DHZC), Charité - Universitätsmedizin Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research) Partner Site, Berlin, Germany
- Department of Health Science and Technology, ETH Zurich, Zurich, Switzerland
| | - Hatem Alkadhi
- Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Reza Hajhosseiny
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Pál Maurovich-Horvat
- Department of Radiology, Medical Imaging Center, Semmelweis University, Budapest, Hungary
| | - Robert Manka
- Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Sebastian Kozerke
- Institute for Biomedical Engineering, ETH Zurich, University of Zurich, Zurich, Switzerland
| | - Matthias Stuber
- Department of Radiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Thorsten Derlin
- Department of Nuclear Medicine, Hannover Medical School, Hannover, Germany
| | - Keith M Channon
- Radcliffe Department of Medicine, University of Oxford and Oxford University Hospitals, Oxford, UK
| | - Ivana Išgum
- Department of Biomedical Engineering and Physics, Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Adriaan Coenen
- Department of Radiology, Erasmus University, Rotterdam, Netherlands
| | - Bernhard Foellmer
- Department of Radiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Damini Dey
- Departments of Biomedical Sciences and Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Rick H J A Volleberg
- Department of Cardiology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Felix G Meinel
- Department of Radiology, University Medical Centre Rostock, Rostock, Germany
| | - Marc R Dweck
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Jan J Piek
- Department of Clinical and Experimental Cardiology and Cardiovascular Sciences, Amsterdam UMC, Heart Center, University of Amsterdam, Amsterdam, Netherlands
| | - Tim van de Hoef
- Department of Cardiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Ulf Landmesser
- DZHK (German Centre for Cardiovascular Research) Partner Site, Berlin, Germany
- Department of Cardiology, Deutsches Herzzentrum der Charité (DHZC), Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Giulio Guagliumi
- Division of Cardiology, IRCCS Galeazzi Sant'Ambrogio Hospital, Milan, Italy
| | - Andreas A Giannopoulos
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - René M Botnar
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
- Institute for Biological and Medical Engineering, Pontificia Universidad Católica de Chile, Millennium Institute for Intelligent Healthcare Engineering, Santiago, Chile
| | - Ramzi Khamis
- National Heart and Lung Institute, Imperial College London, London, UK
| | | | - David E Newby
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Marc Dewey
- Department of Radiology, Charité - Universitätsmedizin Berlin, Berlin, Germany.
- DZHK (German Centre for Cardiovascular Research) Partner Site, Berlin, Germany.
- Deutsches Herzzentrum der Charité (DHZC), Charité - Universitätsmedizin Berlin, Berlin, Germany.
- Berlin Institute of Health, Campus Charité Mitte, Berlin, Germany.
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15
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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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16
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Strube T, Chew DP. Can CTCA provide health care equity for people in rural Australia with coronary artery disease? Med J Aust 2023; 219:153-154. [PMID: 37455256 DOI: 10.5694/mja2.52042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 06/16/2023] [Accepted: 06/23/2023] [Indexed: 07/18/2023]
Affiliation(s)
- Taylor Strube
- Southern Adelaide Local Health Network, Adelaide, SA
| | - Derek P Chew
- Flinders University, Adelaide, SA
- Victorian Heart Hospital and Victorian Heart Institute, Monash University, Melbourne, VIC
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17
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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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18
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Lu ZF, Yin WH, Schoepf UJ, Abrol S, Ma JW, Yu XB, Zhao L, Su XM, Wang CS, An YQ, Xiao ZC, Lu B. Residual Risk in Non-ST-Segment Elevation Acute Coronary Syndrome: Quantitative Plaque Analysis at Coronary CT Angiography. Radiology 2023; 308:e230124. [PMID: 37606570 DOI: 10.1148/radiol.230124] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2023]
Abstract
Background Lipid-rich plaques detected with intravascular imaging are associated with adverse cardiovascular events in patients with non-ST-segment elevation (NSTE) acute coronary syndrome (ACS). But evidence about the prognostic implication of coronary CT angiography (CCTA) in NSTE ACS is limited. Purpose To assess whether quantitative variables at CCTA that reflect lipid content in nonrevascularized plaques in individuals with NSTE ACS might be predictors of subsequent nonrevascularized plaque-related major adverse cardiovascular events (MACEs). Materials and Methods In this multicenter prospective cohort study, from November 2017 to January 2019, individuals diagnosed with NSTE ACS (excluding those at very high risk) were enrolled and underwent CCTA before invasive coronary angiography (ICA) within 1 day. Lipid core was defined as areas with attenuation less than 30 HU in plaques. MACEs were defined as cardiac death, myocardial infarction, hospitalization for unstable angina, and revascularization. Participants were followed up at 6 months, 12 months, and annually thereafter for at least 3 years (ending by July 2022). Multivariable analysis using Cox proportional hazards regression models was performed to determine the association between lipid core burden, lipid core volume, and future nonrevascularized plaque-related MACEs at both the participant and plaque levels. Results A total of 342 participants (mean age, 57.9 years ± 11.1 [SD]; 263 male) were included for analysis with a median follow-up period of 4.0 years (IQR, 3.6-4.4 years). The 4-year nonrevascularized plaque-related MACE rate was 23.9% (95% CI: 19.1, 28.5). Lipid core burden (hazard ratio [HR], 12.6; 95% CI: 4.6, 34.3) was an independent predictor at the participant level, with an optimum threshold of 2.8%. Lipid core burden (HR, 12.1; 95% CI: 6.6, 22.3) and volume (HR, 11.0; 95% CI: 6.5, 18.4) were independent predictors at the plaque level, with an optimum threshold of 7.2% and 10.1 mm3, respectively. Conclusion In NSTE ACS, quantitative analysis of plaque lipid content at CCTA independently predicted participants and plaques at higher risk for future nonrevascularized plaque-related MACEs. Chinese Clinical Trial Registry no. ChiCTR1800018661 © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Tavakoli and Duman in this issue.
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Affiliation(s)
- Zhong-Fei Lu
- From the Department of Radiology (Z.F.L., W.H.Y., J.W.M., L.Z., Y.Q.A., B.L.), NHC Key Laboratory of Clinical Research for Cardiovascular Medications (X.M.S.), and Medical Research & Biometrics Center (C.S.W.), State Key Laboratory of Cardiovascular Disease, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, #167 Bei-Li-Shi Street, Beijing 100037, People's Republic of China; Departments of Radiology (Z.F.L.) and Cardiology (Z.C.X.), Yantai Yuhuangding Hospital, Qingdao University, Yantai, People's Republic of China; Department of Radiology and Radiological Science and Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC (U.J.S., S.A.); and CT Collaboration, Siemens Healthineers, Beijing, People's Republic of China (X.B.Y.)
| | - Wei-Hua Yin
- From the Department of Radiology (Z.F.L., W.H.Y., J.W.M., L.Z., Y.Q.A., B.L.), NHC Key Laboratory of Clinical Research for Cardiovascular Medications (X.M.S.), and Medical Research & Biometrics Center (C.S.W.), State Key Laboratory of Cardiovascular Disease, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, #167 Bei-Li-Shi Street, Beijing 100037, People's Republic of China; Departments of Radiology (Z.F.L.) and Cardiology (Z.C.X.), Yantai Yuhuangding Hospital, Qingdao University, Yantai, People's Republic of China; Department of Radiology and Radiological Science and Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC (U.J.S., S.A.); and CT Collaboration, Siemens Healthineers, Beijing, People's Republic of China (X.B.Y.)
| | - U Joseph Schoepf
- From the Department of Radiology (Z.F.L., W.H.Y., J.W.M., L.Z., Y.Q.A., B.L.), NHC Key Laboratory of Clinical Research for Cardiovascular Medications (X.M.S.), and Medical Research & Biometrics Center (C.S.W.), State Key Laboratory of Cardiovascular Disease, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, #167 Bei-Li-Shi Street, Beijing 100037, People's Republic of China; Departments of Radiology (Z.F.L.) and Cardiology (Z.C.X.), Yantai Yuhuangding Hospital, Qingdao University, Yantai, People's Republic of China; Department of Radiology and Radiological Science and Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC (U.J.S., S.A.); and CT Collaboration, Siemens Healthineers, Beijing, People's Republic of China (X.B.Y.)
| | - Sameer Abrol
- From the Department of Radiology (Z.F.L., W.H.Y., J.W.M., L.Z., Y.Q.A., B.L.), NHC Key Laboratory of Clinical Research for Cardiovascular Medications (X.M.S.), and Medical Research & Biometrics Center (C.S.W.), State Key Laboratory of Cardiovascular Disease, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, #167 Bei-Li-Shi Street, Beijing 100037, People's Republic of China; Departments of Radiology (Z.F.L.) and Cardiology (Z.C.X.), Yantai Yuhuangding Hospital, Qingdao University, Yantai, People's Republic of China; Department of Radiology and Radiological Science and Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC (U.J.S., S.A.); and CT Collaboration, Siemens Healthineers, Beijing, People's Republic of China (X.B.Y.)
| | - Jing-Wen Ma
- From the Department of Radiology (Z.F.L., W.H.Y., J.W.M., L.Z., Y.Q.A., B.L.), NHC Key Laboratory of Clinical Research for Cardiovascular Medications (X.M.S.), and Medical Research & Biometrics Center (C.S.W.), State Key Laboratory of Cardiovascular Disease, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, #167 Bei-Li-Shi Street, Beijing 100037, People's Republic of China; Departments of Radiology (Z.F.L.) and Cardiology (Z.C.X.), Yantai Yuhuangding Hospital, Qingdao University, Yantai, People's Republic of China; Department of Radiology and Radiological Science and Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC (U.J.S., S.A.); and CT Collaboration, Siemens Healthineers, Beijing, People's Republic of China (X.B.Y.)
| | - Xian-Bo Yu
- From the Department of Radiology (Z.F.L., W.H.Y., J.W.M., L.Z., Y.Q.A., B.L.), NHC Key Laboratory of Clinical Research for Cardiovascular Medications (X.M.S.), and Medical Research & Biometrics Center (C.S.W.), State Key Laboratory of Cardiovascular Disease, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, #167 Bei-Li-Shi Street, Beijing 100037, People's Republic of China; Departments of Radiology (Z.F.L.) and Cardiology (Z.C.X.), Yantai Yuhuangding Hospital, Qingdao University, Yantai, People's Republic of China; Department of Radiology and Radiological Science and Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC (U.J.S., S.A.); and CT Collaboration, Siemens Healthineers, Beijing, People's Republic of China (X.B.Y.)
| | - Li Zhao
- From the Department of Radiology (Z.F.L., W.H.Y., J.W.M., L.Z., Y.Q.A., B.L.), NHC Key Laboratory of Clinical Research for Cardiovascular Medications (X.M.S.), and Medical Research & Biometrics Center (C.S.W.), State Key Laboratory of Cardiovascular Disease, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, #167 Bei-Li-Shi Street, Beijing 100037, People's Republic of China; Departments of Radiology (Z.F.L.) and Cardiology (Z.C.X.), Yantai Yuhuangding Hospital, Qingdao University, Yantai, People's Republic of China; Department of Radiology and Radiological Science and Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC (U.J.S., S.A.); and CT Collaboration, Siemens Healthineers, Beijing, People's Republic of China (X.B.Y.)
| | - Xiao-Ming Su
- From the Department of Radiology (Z.F.L., W.H.Y., J.W.M., L.Z., Y.Q.A., B.L.), NHC Key Laboratory of Clinical Research for Cardiovascular Medications (X.M.S.), and Medical Research & Biometrics Center (C.S.W.), State Key Laboratory of Cardiovascular Disease, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, #167 Bei-Li-Shi Street, Beijing 100037, People's Republic of China; Departments of Radiology (Z.F.L.) and Cardiology (Z.C.X.), Yantai Yuhuangding Hospital, Qingdao University, Yantai, People's Republic of China; Department of Radiology and Radiological Science and Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC (U.J.S., S.A.); and CT Collaboration, Siemens Healthineers, Beijing, People's Republic of China (X.B.Y.)
| | - Chuang-Shi Wang
- From the Department of Radiology (Z.F.L., W.H.Y., J.W.M., L.Z., Y.Q.A., B.L.), NHC Key Laboratory of Clinical Research for Cardiovascular Medications (X.M.S.), and Medical Research & Biometrics Center (C.S.W.), State Key Laboratory of Cardiovascular Disease, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, #167 Bei-Li-Shi Street, Beijing 100037, People's Republic of China; Departments of Radiology (Z.F.L.) and Cardiology (Z.C.X.), Yantai Yuhuangding Hospital, Qingdao University, Yantai, People's Republic of China; Department of Radiology and Radiological Science and Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC (U.J.S., S.A.); and CT Collaboration, Siemens Healthineers, Beijing, People's Republic of China (X.B.Y.)
| | - Yun-Qiang An
- From the Department of Radiology (Z.F.L., W.H.Y., J.W.M., L.Z., Y.Q.A., B.L.), NHC Key Laboratory of Clinical Research for Cardiovascular Medications (X.M.S.), and Medical Research & Biometrics Center (C.S.W.), State Key Laboratory of Cardiovascular Disease, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, #167 Bei-Li-Shi Street, Beijing 100037, People's Republic of China; Departments of Radiology (Z.F.L.) and Cardiology (Z.C.X.), Yantai Yuhuangding Hospital, Qingdao University, Yantai, People's Republic of China; Department of Radiology and Radiological Science and Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC (U.J.S., S.A.); and CT Collaboration, Siemens Healthineers, Beijing, People's Republic of China (X.B.Y.)
| | - Zhi-Cheng Xiao
- From the Department of Radiology (Z.F.L., W.H.Y., J.W.M., L.Z., Y.Q.A., B.L.), NHC Key Laboratory of Clinical Research for Cardiovascular Medications (X.M.S.), and Medical Research & Biometrics Center (C.S.W.), State Key Laboratory of Cardiovascular Disease, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, #167 Bei-Li-Shi Street, Beijing 100037, People's Republic of China; Departments of Radiology (Z.F.L.) and Cardiology (Z.C.X.), Yantai Yuhuangding Hospital, Qingdao University, Yantai, People's Republic of China; Department of Radiology and Radiological Science and Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC (U.J.S., S.A.); and CT Collaboration, Siemens Healthineers, Beijing, People's Republic of China (X.B.Y.)
| | - Bin Lu
- From the Department of Radiology (Z.F.L., W.H.Y., J.W.M., L.Z., Y.Q.A., B.L.), NHC Key Laboratory of Clinical Research for Cardiovascular Medications (X.M.S.), and Medical Research & Biometrics Center (C.S.W.), State Key Laboratory of Cardiovascular Disease, National Clinical Research Center for Cardiovascular Diseases, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, #167 Bei-Li-Shi Street, Beijing 100037, People's Republic of China; Departments of Radiology (Z.F.L.) and Cardiology (Z.C.X.), Yantai Yuhuangding Hospital, Qingdao University, Yantai, People's Republic of China; Department of Radiology and Radiological Science and Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC (U.J.S., S.A.); and CT Collaboration, Siemens Healthineers, Beijing, People's Republic of China (X.B.Y.)
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19
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Berry C, Kramer CM, Kunadian V, Patel TR, Villines T, Kwong RY, Raharjo DE. Great Debate: Computed tomography coronary angiography should be the initial diagnostic test in suspected angina. Eur Heart J 2023; 44:2366-2375. [PMID: 36917627 PMCID: PMC10327881 DOI: 10.1093/eurheartj/ehac597] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Affiliation(s)
- Colin Berry
- British Heart Foundation Glasgow Cardiovascular Research Centre, 126 University Place, University of Glasgow, Glasgow, G128TA, UK
- Golden Jubilee National Hospital, Agamemnon Street, Clydebank, G81 4DY, UK
| | - Christopher M Kramer
- Cardiovascular Division, Department of Medicine, University of Virginia Health System, 1215 Lee St., Box 800158, Charlottesville, VA 22908, USA
- Department of Radiology and Medical Imaging, University of Virginia Health System, 1215 Lee St., Box 800170, Charlottesville, VA 22908, USA
| | - Vijay Kunadian
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, 4th Floor William Leech Building, Newcastle upon Tyne NE2 4HH, UK
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Toral R Patel
- Cardiovascular Division, Department of Medicine, University of Virginia Health System, 1215 Lee St., Box 800158, Charlottesville, VA 22908, USA
| | - Todd Villines
- Cardiovascular Division, Department of Medicine, University of Virginia Health System, 1215 Lee St., Box 800158, Charlottesville, VA 22908, USA
| | - Raymond Y Kwong
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Daniell Edward Raharjo
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, 4th Floor William Leech Building, Newcastle upon Tyne NE2 4HH, UK
- Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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20
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Eng-Frost J, Rocheleau S, Lambrakis K, Khan E, van den Merkhof A, Papendick C, Lehman S, Chiang B, Wattchow N, Steele S, Lorensini S, McCann M, George K, Vaile J, De Pasquale C, French J, Chew D. Contrasting the potential benefits of early invasive coronary angiography in acute and chronic myocardial injury patterns. PLoS One 2023; 18:e0286157. [PMID: 37319181 PMCID: PMC10270641 DOI: 10.1371/journal.pone.0286157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 05/10/2023] [Indexed: 06/17/2023] Open
Abstract
BACKGROUND In cases of evolving myocardial injury not definitively attributed to coronary ischaemia precipitated by plaque rupture, referral for invasive coronary angiography (ICA) may be influenced by observed troponin profiles. We sought to explore association between early ICA and elevated high-sensitivity troponin T (hs-cTnT) concentrations with and without dynamic changes, to examine if there may be a hs-cTnT threshold associated with benefit from an initial ICA strategy. METHODS Using published studies (hs-cTnT study n = 1937, RAPID-TnT study n = 3270) and the Fourth Universal Definition of Myocardial Infarction (MI), index presentations of patients with hs-cTnT concentrations 5-14ng/L were classified as 'non-elevated' (NE). Hs-cTnT greater than upper reference limit (14ng/L) were classified as 'elevated hs-cTnT with dynamic change' (encompassing acute myocardial injury, Type 1 MI, and Type 2 MI), or 'non-dynamic hs-cTnT elevation' (chronic myocardial injury). Patients with hs-cTnT <5ng/L and/or eGFR<15mmol/L/1.73m2 were excluded. ICA was performed within 30 days of admission. Primary outcome was defined as composite endpoint of death, MI, or unstable angina at 12 months. RESULTS Altogether, 3620 patients comprising 837 (23.1%) with non-dynamic hs-cTnT elevations and 332 (9.2%) with dynamic hs-cTnT elevations were included. Primary outcome was significantly higher with dynamic and non-dynamic hs-cTnT elevations (Dynamic: HR: 4.13 95%CI:2.92-5.82; p<0.001 Non-dynamic: HR: 2.39 95% confidence interval [CI]:1.74-3.28, p<0.001). Hs-cTnT thresholds where benefit from initial ICA strategy appeared to emerge was observed at 110ng/L and 50ng/L in dynamic and non-dynamic elevations, respectively. CONCLUSION Early ICA appears to portend benefit in hs-cTnT elevations with and without dynamic changes, and at lower hs-cTnT threshold in non-dynamic hs-cTnT elevation. Differences compel further investigation.
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Affiliation(s)
- Joanne Eng-Frost
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, Australia
| | - Simon Rocheleau
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, Australia
| | - Kristina Lambrakis
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, Australia
| | - Ehsan Khan
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, Australia
| | - Anke van den Merkhof
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia
- Faculty of Medical Sciences, University of Groningen, Groningen, Netherlands
| | | | - Sam Lehman
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, Australia
| | - Brian Chiang
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, Australia
| | - Naomi Wattchow
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, Australia
| | - Simon Steele
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, Australia
| | - Scott Lorensini
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, Australia
| | - Michael McCann
- Department of Cardiology, Fiona Stanley Hospital, Perth, Australia
| | - Kate George
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, Australia
| | - Julian Vaile
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, Australia
| | - Carmine De Pasquale
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, Australia
| | - John French
- Department of Cardiology, Liverpool Hospital, Sydney, Australia
| | - Derek Chew
- College of Medicine & Public Health, Flinders University of South Australia, Adelaide, Australia
- Department of Cardiovascular Medicine, Flinders Medical Centre, Adelaide, Australia
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21
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Miller CD, Mahler SA, Snavely AC, Raman SV, Caterino JM, Clark CL, Jones AE, Hall ME, Koehler LE, Lovato JF, Hiestand BC, Stopyra JP, Park CJ, Vasu S, Kutcher MA, Hundley WG. Cardiac Magnetic Resonance Imaging Versus Invasive-Based Strategies in Patients With Chest Pain and Detectable to Mildly Elevated Serum Troponin: A Randomized Clinical Trial. Circ Cardiovasc Imaging 2023; 16:e015063. [PMID: 37339173 PMCID: PMC10287041 DOI: 10.1161/circimaging.122.015063] [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: 11/08/2022] [Accepted: 04/25/2023] [Indexed: 06/22/2023]
Abstract
BACKGROUND The optimal diagnostic strategy for patients with chest pain and detectable to mildly elevated serum troponin is not known. The objective was to compare clinical outcomes among an early decision for a noninvasive versus an invasive-based care pathway. METHODS The CMR-IMPACT trial (Cardiac Magnetic Resonance Imaging Strategy for the Management of Patients with Acute Chest Pain and Detectable to Elevated Troponin) was conducted at 4 United States tertiary care hospitals from September 2013 to July 2018. A convenience sample of 312 participants with acute chest pain symptoms and a contemporary troponin between detectable and 1.0 ng/mL were randomized early in their care to 1 of 2 care pathways: invasive-based (n=156) or cardiac magnetic resonance (CMR)-based (n=156) with modification allowed as the patient condition evolved. The primary outcome was a composite including death, myocardial infarction, and cardiac-related hospital readmission or emergency visits. RESULTS Participants (N=312, mean age, 60.6 years, SD 11.3; 125 women [59.9%]), were followed over a median of 2.6 years (95% CI, 2.4-2.9). Early assigned testing was initiated in 102 out of 156 (65.3%) CMR-based and 110 out of 156 (70.5%) invasive-based participants. The primary outcome (CMR-based versus invasive-based) occurred in 59% versus 52% (hazard ratio, 1.17 [95% CI, 0.86-1.57]), acute coronary syndrome after discharge 23% versus 22% (hazard ratio, 1.07 [95% CI, 0.67-1.71]), and invasive angiography at any time 52% versus 74% (hazard ratio, 0.66 [95% CI, 0.49-0.87]). Among patients completing CMR imaging, 55 out of 95 (58%) were safely identified for discharge based on a negative CMR and did not have angiography or revascularization within 90 days. Therapeutic yield of angiography was higher in the CMR-based arm (52 interventions in 81 angiographies [64.2%] versus 46 interventions in 115 angiographies [40.0%] in the invasive-based arm [P=0.001]). CONCLUSIONS Initial management with CMR or invasive-based care pathways resulted in no detectable difference in clinical and safety event rates. The CMR-based pathway facilitated safe discharge, enriched the therapeutic yield of angiography, and reduced invasive angiography utilization over long-term follow-up. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT01931852.
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Affiliation(s)
- Chadwick D Miller
- Department of Emergency Medicine (C.D.M., S.AM., A.S., L.K., B.H., J.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Simon A Mahler
- Department of Emergency Medicine (C.D.M., S.AM., A.S., L.K., B.H., J.S.), Wake Forest School of Medicine, Winston-Salem, NC
- Department of Epidemiology and Prevention (S.A.M.), Wake Forest School of Medicine, Winston-Salem, NC
- Department of Implementation Science (S.A.M.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Anna C Snavely
- Department of Emergency Medicine (C.D.M., S.AM., A.S., L.K., B.H., J.S.), Wake Forest School of Medicine, Winston-Salem, NC
- Department of Biostatistics and Data Science (A.S., J.F.L.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Subha V Raman
- Division of Cardiovascular Medicine (S.V.R.), The Ohio State University, Columbus, OH
- Now with Indiana University Krannert Institute of Cardiology, Indianapolis, IN (S.V.R.)
| | - Jeffrey M Caterino
- Department of Emergency Medicine (J.M.C.), The Ohio State University, Columbus, OH
| | - Carol L Clark
- Department of Emergency Medicine, Corewell Health William Beaumont University Hospital, Royal Oak, MI (C.L.C.)
| | - Alan E Jones
- Department of Emergency Medicine (A.E.J.), University of Mississippi Medical Center, Jackson, MS
| | - Michael E Hall
- Department of Medicine (M.E.H.), University of Mississippi Medical Center, Jackson, MS
| | - Lauren E Koehler
- Department of Emergency Medicine (C.D.M., S.AM., A.S., L.K., B.H., J.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - James F Lovato
- Department of Biostatistics and Data Science (A.S., J.F.L.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Brian C Hiestand
- Department of Emergency Medicine (C.D.M., S.AM., A.S., L.K., B.H., J.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Jason P Stopyra
- Department of Emergency Medicine (C.D.M., S.AM., A.S., L.K., B.H., J.S.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Carolyn J Park
- Department of Internal Medicine/Cardiology (C.P., S.V., M.A.K., W.G.H.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Sujethra Vasu
- Department of Internal Medicine/Cardiology (C.P., S.V., M.A.K., W.G.H.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Michael A Kutcher
- Department of Internal Medicine/Cardiology (C.P., S.V., M.A.K., W.G.H.), Wake Forest School of Medicine, Winston-Salem, NC
| | - W Gregory Hundley
- Department of Internal Medicine/Cardiology (C.P., S.V., M.A.K., W.G.H.), Wake Forest School of Medicine, Winston-Salem, NC
- Department of Radiology (W.G.H.), Wake Forest School of Medicine, Winston-Salem, NC
- Department of Internal Medicine/Cardiology, Virginia Commonwealth University School of Medicine, Richmond, VA (W.G.H.)
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22
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Premaratne M, Garcia GP, Thomas W, Hameed S, Leadbeatter A, Htun N, Dwivedi G, Kaye DM. Opportunities and Challenges of Computed Tomography Coronary Angiography in the Investigation of Chest Pain in the Emergency Department-A Narrative Review. Heart Lung Circ 2023; 32:307-314. [PMID: 36621394 DOI: 10.1016/j.hlc.2022.12.004] [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: 05/22/2022] [Revised: 11/02/2022] [Accepted: 12/06/2022] [Indexed: 01/07/2023]
Abstract
Chest pain is one of the most common presentations to emergency departments. However, only 5.1% will be diagnosed with an acute coronary syndrome, representing considerable time and expense in the diagnosis and investigation of the patients eventually found not to be suffering from an acute coronary syndrome. PubMed and Medline databases were searched with variations of the terms "chest pain", "emergency department", "computed tomography coronary angiography". After review, 52 articles were included. Computed tomography coronary angiography (CTCA) is a class I endorsement for investigating chest pain in major international societal guidelines. CTCA offers excellent sensitivity and negative predictive value in identifying patients with coronary disease, with prognostic data impacting patient management. If CTCA is to be applied to all comers, it is pertinent to discuss the advantages and potential pitfalls if use in the Australian system is to be increased.
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Affiliation(s)
- Manuja Premaratne
- Department of Medicine, Cardiology, Peninsula Health, Melbourne, Vic, Australia.
| | | | - William Thomas
- Department of Radiology, Peninsula Health, Melbourne, Vic, Australia
| | - Shaiq Hameed
- Department of Medicine, Peninsula Health, Melbourne, Vic, Australia
| | | | - Nay Htun
- Department of Medicine, Cardiology, Peninsula Health, Melbourne, Vic, Australia
| | - Girish Dwivedi
- Department of Cardiology, Harry Perkins Institute of Medical Research, Perth, WA, Australia
| | - David M Kaye
- Department of Cardiology, Alfred Health, Melbourne, Vic, Australia
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23
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Koh N, Nieman K. Role of cardiac imaging in acute chest pain. Br J Radiol 2023; 96:20220307. [PMID: 36533544 PMCID: PMC9975370 DOI: 10.1259/bjr.20220307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 11/04/2022] [Accepted: 11/18/2022] [Indexed: 12/23/2022] Open
Abstract
Chest pain is the second most common complaint in the emergency department. The need to diagnose the cause of chest pain in a timely manner and appropriately direct care is crucial. This article discusses the role of imaging in acute chest pain, after first differentiating chest pain into cardiac and non-cardiac causes with upfront clinical and biochemical assessment. The role of non-invasive imaging including point-of-care ultrasound, echocardiography, myocardial perfusion imaging, cardiac MRI, coronary computed tomography angiography and novel cardiac CT applications are discussed. Updates in the literature regarding the role of coronary plaque imaging in acute chest pain are reviewed, as are ongoing challenges and future directions. This includes a discussion on the yield of diagnostic testing in low-risk acute chest pain cohorts vs intermediate-high risk cohorts. The incremental value of further testing in the former is low, which is reflected in contemporary guidelines that discourage the use of costly diagnostic tests in these cohorts. In the latter cohort, emerging evidence has shown specifically the role coronary computed tomography angiography could play in reducing the need for invasive coronary angiography in selective patients where the true probability of acute coronary syndrome is thought to be low. Real-world considerations such as accessibility and affordability are also discussed in the paper because while guidelines offer clinicians the flexibility of evidence-based choice, physician decision must necessarily be made in consideration of real-world constraints.
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Affiliation(s)
- Natalie Koh
- Department of Cardiology, National Heart Centre Singapore, Singapore, Singapore
| | - Koen Nieman
- Departments of Cardiovascular Medicine and Radiology, Stanford University, School of Medicine, Stanford, CA, USA
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24
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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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25
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Ratcovich H, Sadjadieh G, Linde JJ, Joshi FR, Kelbæk H, Kofoed KF, Køber L, Hansen PR, Torp-Pedersen C, Elming H, Gislason GH, Høfsten DE, Engstrøm T, Holmvang L. Coronary CT and timing of invasive coronary angiography in patients ≥75 years old with non-ST segment elevation acute coronary syndromes. Heart 2023; 109:457-463. [PMID: 36351794 DOI: 10.1136/heartjnl-2022-321640] [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: 07/19/2022] [Accepted: 10/25/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The ability of coronary CT angiography (cCTA) to rule out significant coronary artery disease (CAD) in older patients with non-ST segment elevation acute coronary syndromes (NSTEACS) is unclear since valid cCTA analysis may be limited by extensive coronary artery calcification. In addition, the effect of very early invasive coronary angiography (ICA) with possible revascularisation is debated. METHODS This is a posthoc analysis of patients ≥75 years included in the Very Early vs Standard Care Invasive Examination and Treatment of Patients with Non-ST-Segment Elevation Acute Coronary Syndrome Trial. cCTA was performed prior to the ICA. The diagnostic accuracy of cCTA was investigated. Presence of a coronary artery stenosis ≥50% by subsequent ICA was used as reference. Patients were randomised to a very early (within 12 hours of diagnosis) or a standard ICA (within 48-72 hours of diagnosis). The primary composite endpoint was 5-year all-cause mortality, non-fatal recurrent myocardial infarction or hospital admission for refractory myocardial ischaemia or heart failure. RESULTS Of 452 (21%) patients ≥75 years, 161 (35.6%) underwent cCTA. 19% of cCTAs excluded significant CAD. The negative predictive value (NPV) of cCTA was 94% (95% CI 79 to 99) and the sensitivity 98% (95% CI 94 to 100). No significant differences in the frequency of primary endpoints were seen in patients randomised to very early ICA (at 5-year follow-up, n=100 (46.9%) vs 122 (51.0%), log-rank p=0.357). CONCLUSION In patients ≥75 years with NSTEACS, cCTA before ICA showed a high NPV. A very early ICA <12 hours of diagnosis did not significantly improve long-term clinical outcomes.
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Affiliation(s)
- Hanna Ratcovich
- Rigshospitalet, Department of Cardiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Golnaz Sadjadieh
- Rigshospitalet, Department of Cardiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jesper J Linde
- Rigshospitalet, Department of Cardiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Francis R Joshi
- Rigshospitalet, Department of Cardiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Henning Kelbæk
- Department of Cardiology, Zealand University Hospital Roskilde, Roskilde, Denmark
| | - Klaus F Kofoed
- Rigshospitalet, Department of Cardiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Lars Køber
- Rigshospitalet, Department of Cardiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Peter Riis Hansen
- Department of Cardiology, Gentofte University Hospital, Hellerup, Denmark
| | - Christian Torp-Pedersen
- Department of Clinical Investigation and Cardiology, Nordsjællands Hospital, Hillerød, Denmark
| | - Hanne Elming
- Department of Cardiology, Zealand University Hospital Roskilde, Roskilde, Denmark
| | | | - Dan Eik Høfsten
- Rigshospitalet, Department of Cardiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Thomas Engstrøm
- Rigshospitalet, Department of Cardiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Lene Holmvang
- Rigshospitalet, Department of Cardiology, Copenhagen University Hospital, Copenhagen, Denmark
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26
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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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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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28
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Kontos MC, de Lemos JA, Deitelzweig SB, Diercks DB, Gore MO, Hess EP, McCarthy CP, McCord JK, Musey PI, Villines TC, Wright LJ. 2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2022; 80:1925-1960. [PMID: 36241466 PMCID: PMC10691881 DOI: 10.1016/j.jacc.2022.08.750] [Citation(s) in RCA: 40] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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29
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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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30
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Meah MN, Tzolos E, Wang KL, Bularga A, Dweck MR, Curzen N, Kardos A, Keating L, Storey RF, Mills NL, Slomka PJ, Dey D, Newby DE, Gray A, Williams MC, Roobottom C. Plaque Burden and 1-Year Outcomes in Acute Chest Pain: Results From the Multicenter RAPID-CTCA Trial. JACC Cardiovasc Imaging 2022; 15:1916-1925. [PMID: 36357133 DOI: 10.1016/j.jcmg.2022.04.024] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/25/2022] [Accepted: 04/29/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND In patients with stable chest pain, computed tomography (CT) plaque burden is an independent predictor of future coronary events. OBJECTIVES The purpose of this study was to determine whether plaque burden and characteristics can predict subsequent death or myocardial infarction in patients with acute chest pain. METHODS In a post hoc analysis of a multicenter trial of early coronary CT angiography, the authors performed quantitative plaque analysis to assess the association between primary endpoint of 1-year all-cause death or nonfatal myocardial infarction and the GRACE (Global Registry of Acute Coronary Events) score, presence of obstructive coronary artery disease, and plaque burden in 404 patients with suspected acute coronary syndrome. RESULTS Following the index event, 25 patients had a primary event that was associated with a higher GRACE score (134 ± 44 vs 113 ± 35; P = 0.012), larger burdens of total (46% [IQR: 43%-50%] vs 36% [IQR: 21%-46%]; P < 0.001), noncalcified (41% [IQR: 37%-%47] vs 33% [IQR: 20%-41%]; P < 0.001), and low-attenuation plaque (4.22% [IQR: 3.3%-5.68%] vs 2.14% [IQR: 0.5%-4.88%]; P < 0.001), but not obstructive coronary artery disease (P = 0.065). Total, noncalcified, and low-attenuation plaque burden were the strongest predictors of future events independent of GRACE score and obstructive coronary artery disease (P ≤ 0.002 for all). Patients with a low-attenuation burden above the median had nearly an 8-fold increased risk of the primary endpoint (HR: 7.80 [95% CI: 2.33-26.0]; P < 0.001), outperforming either a GRACE score of >140 (HR: 3.80 [95% CI :1.45-6.98]; P = 0.004) or obstructive coronary artery disease (HR: 2.07 [95% CI: 0.94-4.53]; P = 0.07). CONCLUSIONS In patients with suspected acute coronary syndrome, low-attenuation plaque burden is a major predictor of 1-year death or recurrent myocardial infarction. (Rapid Assessment of Potential Ischaemic Heart Disease With CTCA [RAPID-CTCA]; NCT02284191).
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Affiliation(s)
- Mohammed N Meah
- BHF Centre of Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom.
| | - Evangelos Tzolos
- BHF Centre of Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Kang-Ling Wang
- BHF Centre of Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Anda Bularga
- BHF Centre of Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Marc R Dweck
- BHF Centre of Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Nick Curzen
- Faculty of Medicine, University of Southampton, Southampton, United Kingdom; University Hospital Southampton, Southampton, United Kingdom
| | - Attila Kardos
- Department of Cardiology Milton Keynes University Hospital, School of Sciences and Medicine, University of Buckingham, Buckingham, United Kingdom
| | - Liza Keating
- Royal Berkshire NHS Foundation Trust, Reading, United Kingdom
| | | | - Nicholas L Mills
- BHF Centre of Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Piotr J Slomka
- Departments of Medicine and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Damini Dey
- Departments of Medicine and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - David E Newby
- BHF Centre of Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Edinburgh Imaging, Queen's Medical Research Institute University of Edinburgh, Edinburgh, United Kingdom
| | - Alasdair Gray
- BHF Centre of Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Michelle C Williams
- BHF Centre of Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Edinburgh Imaging, Queen's Medical Research Institute University of Edinburgh, Edinburgh, United Kingdom
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31
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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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32
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Meah MN, Bularga A, Tzolos E, Chapman AR, Daghem M, Hung JD, Chiong J, Taggart C, Wereski R, Gray A, Dweck MR, Roobottom C, Curzen N, Kardos A, Felmeden D, Mills NL, Slomka PJ, Newby DE, Dey D, Williams MC. Distinguishing Type 1 from Type 2 Myocardial Infarction by Using CT Coronary Angiography. Radiol Cardiothorac Imaging 2022; 4:e220081. [PMID: 36339063 PMCID: PMC9627233 DOI: 10.1148/ryct.220081] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 09/23/2022] [Accepted: 10/04/2022] [Indexed: 01/25/2023]
Abstract
Purpose To determine whether quantitative plaque characterization by using CT coronary angiography (CTCA) can discriminate between type 1 and type 2 myocardial infarction. Materials and Methods This was a secondary analysis of two prospective studies (ClinicalTrials.gov registration nos. NCT03338504 [2014-2019] and NCT02284191 [2018-2020]) that performed blinded quantitative plaque analysis on findings from CTCA in participants with type 1 myocardial infarction, type 2 myocardial infarction, and chest pain without myocardial infarction. Logistic regression analyses were performed to identify predictors of type 1 myocardial infarction. Results Overall, 155 participants (mean age, 64 years ± 12 [SD]; 114 men) and 36 participants (mean age, 67 years ± 12; 19 men) had type 1 and type 2 myocardial infarction, respectively, and 136 participants (62 years ± 12; 78 men) had chest pain without myocardial infarction. Participants with type 1 myocardial infarction had greater total (median, 44% [IQR: 35%-50%] vs 35% [IQR: 29%-46%]), noncalcified (39% [IQR: 31%-46%] vs 34% [IQR: 29%-40%]), and low-attenuation (4.15% [IQR: 1.88%-5.79%] vs 1.64% [IQR: 0.89%-2.28%]) plaque burdens (P < .05 for all) than those with type 2. Participants with type 2 myocardial infarction had similar low-attenuation plaque burden to those with chest pain without myocardial infarction (P = .4). Low-attenuation plaque was an independent predictor of type 1 myocardial infarction (adjusted odds ratio, 3.44 [95% CI: 1.84, 6.96]; P < .001), with better discrimination than noncalcified plaque burden and maximal area of coronary stenosis (C statistic, 0.75 [95% CI: 0.67, 0.83] vs 0.62 [95% CI: 0.53, 0.71] and 0.61 [95% CI: 0.51, 0.70] respectively; P ≤ .001 for both). Conclusion Higher low-attenuation coronary plaque burden in patients with type 1 myocardial infarction may help distinguish these patients from those with type 2 myocardial infarction.Keywords: Ischemia/Infarction, CT Angiography, Quantitative CTClinical trial registration nos. NCT03338504 and NCT02284191 Supplemental material is available for this article. © RSNA, 2022.
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Affiliation(s)
- Mohammed N. Meah
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - Anda Bularga
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - Evangelos Tzolos
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - Andrew R. Chapman
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - Marwa Daghem
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - John D. Hung
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - Justin Chiong
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - Caelan Taggart
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - Ryan Wereski
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - Alasdair Gray
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - Marc R. Dweck
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - Carl Roobottom
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - Nick Curzen
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - Attila Kardos
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - Dirk Felmeden
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - Nicholas L. Mills
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - Piotr J. Slomka
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
| | - David E. Newby
- From the British Heart Foundation Centre of Cardiovascular Science,
University of Edinburgh, Edinburgh, Scotland (M.N.M., A.B., E.T., A.R.C., M.D.,
J.D.H., J.C., C.T., R.W., A.G., M.R.D., N.L.M., D.E.N., M.C.W.); Usher
Institute, University of Edinburgh, Edinburgh, Scotland (A.G., N.L.M.);
University Hospital Plymouth, Plymouth, England (C.R.); Faculty of Medicine,
University of Southampton, Southampton, England (N.C.); University Hospital
Southampton, Southampton, England (N.C.); Department of Cardiology, Milton
Keynes University Hospital, School of Sciences and Medicine, University of
Buckingham, Buckingham, England (A.K.); Torbay and South Devon NHS Foundation
Trust, Torquay, England (D.F.); Departments of Medicine and Biomedical Sciences,
Cedars-Sinai Medical Center, Los Angeles, Calif (P.J.S., D.D.); and Edinburgh
Imaging, Queen’s Medical Research Institute University of Edinburgh,
Edinburgh, Scotland (D.E.N., M.C.W.)
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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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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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Frühe Coro-CT bewährt sich bei intermediärem KHK-Risiko nicht. AKTUELLE KARDIOLOGIE 2022. [DOI: 10.1055/a-1840-2462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Hulten E, Murthy VL. Thinking outside the box: clinical and economic implications of extracardiac findings on cardiac computed tomography angiography. Heart 2022; 108:1426-1427. [DOI: 10.1136/heartjnl-2022-321009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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37
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Blankstein R, Shaw LJ, Gulati M, Atalay MK, Bax J, Calnon DA, Dyke CK, Ferencik M, Heitner JF, Henry TD, Hung J, Knuuti J, Lindner JR, Phillips LM, Raman SV, Rao SV, Rybicki FJ, Saraste A, Stainback RF, Thompson RC, Williamson E, Nieman K, Tremmel JA, Woodard PK, Di Carli MF, Chandrashekhar YS. Implications of the 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Chest Pain Guideline for Cardiovascular Imaging: A Multisociety Viewpoint. JACC Cardiovasc Imaging 2022; 15:912-926. [PMID: 35512960 DOI: 10.1016/j.jcmg.2022.02.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 02/23/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Ron Blankstein
- Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA.
| | - Leslee J Shaw
- Departments of Medicine (Cardiology) and Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Martha Gulati
- Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Michael K Atalay
- Department of Diagnostic Imaging, Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA
| | - Jeroen Bax
- Heart Center, Turku University Hospital, Turku, Finland; Leiden University Medical Centre, Leiden, the Netherlands
| | - Dennis A Calnon
- Ohio Health Heart & Vascular Physicians, Columbus, Ohio, USA
| | | | - Maros Ferencik
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
| | | | - Timothy D Henry
- The Carl and Edyth Lindner Center for Research and Education at The Christ Hospital, Cincinnati, Ohio, USA
| | - Judy Hung
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Juhani Knuuti
- Heart Center, Turku University Hospital, Turku, Finland
| | - Jonathan R Lindner
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
| | | | - Subha V Raman
- Indiana University CV Institute and Krannert CV Research Center, Indianapolis, Indiana, USA
| | - Sunil V Rao
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Frank J Rybicki
- University of Cincinnati, College of Medicine, Cincinnati, Ohio, USA
| | - Antti Saraste
- Heart Center, Turku University Hospital, Turku, Finland; Turku PET Centre, Turku University Hospital and University of Turku, Turku, Finland
| | - Raymond F Stainback
- Texas Heart Institute and Baylor College of Medicine, Division of Cardiology, Houston, Texas, USA
| | - Randall C Thompson
- St. Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, Missouri, USA
| | | | - Koen Nieman
- Stanford University, Palo Alto, California, USA
| | | | - Pamela K Woodard
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Marcelo F Di Carli
- Cardiovascular Imaging Program, Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Khawaja T, Janus S, Al-Kindi SG. Role of Coronary CT Angiography in the Evaluation of Acute Chest Pain and Suspected or Confirmed Acute Coronary Syndrome. US CARDIOLOGY REVIEW 2022. [DOI: 10.15420/usc.2021.30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Advances in CT technology have resulted in improved imaging of the coronary anatomy in patients with stable coronary artery disease, using coronary CT angiography (CCTA). Recent data suggest that CCTA may play a role in higher risk patients, such as those evaluated in the emergency room with acute chest pain. Data thus far support the use of CCTA in low-risk patients with acute chest pain. Recent literature suggests that CCTA may play a role in the risk stratification of selected intermediate-risk patients. In this review, the authors discuss the emerging role of CCTA in higher risk patients, such as those with suspected or confirmed acute coronary syndrome (ACS). The excellent accuracy of CCTA in detecting obstructive coronary artery disease in patients with ACS is detailed, along with a highlighting of the safety of using CCTA in this setting. The authors also discuss the role for CCTA atheromatous plaque characterization, which is being increasingly recognized as an important predictor of clinical outcomes.
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Affiliation(s)
- Tasveer Khawaja
- Department of Medicine, Harrington Heart & Vascular Institute, University Hospitals, Cleveland, OH
| | - Scott Janus
- Department of Medicine, Harrington Heart & Vascular Institute, University Hospitals, Cleveland, OH
| | - Sadeer G Al-Kindi
- Department of Medicine, Harrington Heart & Vascular Institute, University Hospitals, Cleveland, OH
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39
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Frühe CT-Angiografie bewährt sich bei intermediärem KHK-Risiko nicht. Dtsch Med Wochenschr 2022. [DOI: 10.1055/a-1665-1348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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40
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Cainzos-Achirica M, Nasir K. Debates in Cardiac CT: The Force of Data Is with CAC — And It’s Rock Solid. J Cardiovasc Comput Tomogr 2022; 16:286-289. [DOI: 10.1016/j.jcct.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/06/2022] [Accepted: 02/02/2022] [Indexed: 10/19/2022]
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41
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Liuzzo G, Volpe M. Computed tomography coronary angiography in acute chest pain: an excellent diagnostic tool with poor added value on clinical outcomes. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehab766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Giovanna Liuzzo
- Department of Cardiovascular and Pulmonary Sciences, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Catholic University School of Medicine, Largo A. Gemelli, 8, Rome 00168, Italy
| | - Massimo Volpe
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Sant 'Andrea Hospital, Via di Grottarossa, 1035/1039, Rome 00189, Italy
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Arai AE, Kwong RY, Salerno M, Greenwood JP, Bucciarelli-Ducci C. Society for Cardiovascular Magnetic Resonance perspective on the 2021 AHA/ACC Chest Pain Guidelines. J Cardiovasc Magn Reson 2022; 24:8. [PMID: 34980173 PMCID: PMC8722020 DOI: 10.1186/s12968-021-00835-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Accepted: 11/30/2021] [Indexed: 01/02/2023] Open
Affiliation(s)
| | | | | | - John P. Greenwood
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Chiara Bucciarelli-Ducci
- Royal Brompton and Harefield Hospitals, Guys’ and St Thomas NHS Hospitals and School of Biomedical Engineering & Imaging Sciences, King’s College London, London, UK
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McRae AD, O'Rielly CM, Lang ES. High-Sensitivity Cardiac Troponins and Clinical Decision Making in Caring for Patients With Chest Pain. Ann Intern Med 2022; 175:137-138. [PMID: 34807715 DOI: 10.7326/m21-4342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Andrew D McRae
- Departments of Emergency Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Connor M O'Rielly
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Eddy S Lang
- Departments of Emergency Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Bucciarelli-Ducci C, Ajmone-Marsan N, Di Carli M, Nicol E. OUP accepted manuscript. Eur Heart J 2022; 43:1288-1295. [PMID: 35259251 PMCID: PMC8970999 DOI: 10.1093/eurheartj/ehac033] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 01/02/2022] [Accepted: 03/01/2022] [Indexed: 11/12/2022] Open
Abstract
This article reviews the most relevant literature published in 2021 on the role of cardiovascular imaging in cardiovascular medicine. Coronavirus disease 2019 (COVID-19) continued to impact the healthcare landscape, resulting in reduced access to hospital-based cardiovascular care including reduced routine diagnostic cardiovascular testing. However, imaging has also facilitated the understanding of the presence and extent of myocardial damage caused by the coronavirus infection. What has dominated the imaging literature beyond the pandemic are novel data on valvular heart disease, the increasing use of artificial intelligence (AI) applied to imaging, and the use of advanced imaging modalities in both ischaemic heart disease and cardiac amyloidosis.
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Affiliation(s)
- Chiara Bucciarelli-Ducci
- Royal Brompton and Harefield Hospitals, Guys' and St Thomas NHS Trust and School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Corresponding author.
| | - Nina Ajmone-Marsan
- Department of Cardiology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
| | - Marcelo Di Carli
- Cardiovascular Imaging Program, Department of Radiology, Heart and Vascular Center, Harvard Medical School, Boston, MA, USA
- Cardiovascular Imaging Program, Department of Medicine, Heart and Vascular Center, Harvard Medical School, Boston, MA, USA
- Division of Cardiovascular Medicine, Department of Medicine, Harvard Medical School, Boston, MA, USA
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Edward Nicol
- Royal Brompton and Harefield Hospitals, Guys' and St Thomas NHS Trust and School of Biomedical Engineering and Imaging Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
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Barrett L, Adams T, Whitehouse DP, Richter S, Boyle AA, Newcombe V. Journal update monthly top five. Emerg Med J 2021; 39:80-82. [PMID: 34933909 DOI: 10.1136/emermed-2021-212197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 11/29/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Liam Barrett
- Emergency Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK .,University Division of Anaesthesia, Cambridge University, Cambridge, UK
| | - Thomas Adams
- Emergency Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Daniel P Whitehouse
- Emergency Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,University Division of Anaesthesia, Cambridge University, Cambridge, UK
| | - Sophie Richter
- Emergency Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,University Division of Anaesthesia, Cambridge University, Cambridge, UK
| | - Adrian A Boyle
- Emergency Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Virginia Newcombe
- Emergency Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.,University Division of Anaesthesia, Cambridge University, Cambridge, UK
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Shaw LJ, Chandrashekhar Y. What Is of Recent Interest in Cardiac Imaging?: Insights From the JACC Family of Journals. J Am Coll Cardiol 2021; 78:2387-2391. [PMID: 34857099 PMCID: PMC8629342 DOI: 10.1016/j.jacc.2021.10.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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