1
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Alazrag W, Idris H, Saad YM, Etaher A, Ren S, Ferguson I, Juergens C, Chew DP, Otton J, Middleton PM, French JK. Management and outcomes with 5-year mortality of patients with mildly elevated high-sensitivity troponin T levels not meeting criteria for myocardial infarction. Emerg Med Australas 2024; 36:62-70. [PMID: 37705175 DOI: 10.1111/1742-6723.14298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 05/12/2023] [Accepted: 08/08/2023] [Indexed: 09/15/2023]
Abstract
OBJECTIVES To examine management and outcomes of patients presenting to EDs with symptoms suggestive of acute coronary syndrome, who have mild non-dynamically elevated high-sensitivity troponin T (HsTnT) levels, not meeting the fourth universal definition of myocardial infarction (MI) criteria (observation group). METHODS Consecutive patients presenting to the ED with symptoms suggestive of acute coronary syndrome at Liverpool Hospital, Sydney, Australia, those having ≥2 HsTnT levels after initial assessment were adjudicated according to the fourth universal definition of MI, as MI ruled-in, MI ruled-out, or myocardial injury in whom MI is neither ruled-in nor ruled-out (>1 level ≥15 ng/L, called observation group); follow-up was 5 years. RESULTS Of 2738 patients, 547 were in the observation group, of whom 62% were admitted to hospital, 52% to cardiac services, whereas 97% of MI ruled-in patients and 21% of MI ruled-out patients were admitted; P < 0.001. Non-invasive testing occurred in 42% of observation group patients (36% had echo-cardiography), and 16% had coronary angiography. Of observation group patients, MI rates were 1.5% during hospitalisation and 4% during the following year, similar to that in those with MI ruled-in, among those with MI ruled-out, the MI rate was 0.2%. The 1-year death rate was 13% among observation group patients and 11% MI ruled-in patients (P = 0.624), whereas at 5 years among observation group patients, type 1 MI and type 2 MI were 48%, 26% and 58%, respectively (P = 0.001). CONCLUSION Very few unselected consecutive patients attending ED, with minor stable HsTnT elevation, had MI, although most had chronic myocardial injury. Late mortality rates among observation group patients were higher than those with confirmed type 1 MI but lower than those with type 2 MI.
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Affiliation(s)
- Weaam Alazrag
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
- South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Hanan Idris
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
- South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Yousef Me Saad
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
- South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Aisha Etaher
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
- South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Shiquan Ren
- South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Ian Ferguson
- South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
- Department of Emergency Medicine, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Craig Juergens
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
- South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Derek P Chew
- College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
- South Australian Department of Health, Adelaide, South Australia, Australia
| | - James Otton
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
- South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
| | - Paul M Middleton
- South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
- Department of Emergency Medicine, Liverpool Hospital, Sydney, New South Wales, Australia
| | - John K French
- Department of Cardiology, Liverpool Hospital, Sydney, New South Wales, Australia
- South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
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2
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Lan NSR, Thomas DR, Jones CL, Raju V, Soon J, Otto J, Wood C, Briffa T, Dwivedi G, Rankin JM, Ihdayhid AR. Evaluation of stable chest pain following emergency department presentation: Impact of first-line cardiac computed tomography diagnostic strategy in an Australian setting. Emerg Med Australas 2024; 36:31-38. [PMID: 37593996 DOI: 10.1111/1742-6723.14290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/17/2023] [Accepted: 07/19/2023] [Indexed: 08/19/2023]
Abstract
OBJECTIVE International guidelines provide increasing support for computed tomography coronary angiography (CTCA) in investigating chest pain. A pathway utilising CTCA first-line for outpatient stable chest pain evaluation was implemented in an Australian ED. METHODS In pre-post design, the impact of the pathway was prospectively assessed over 6 months (August 2021 to January 2022) and compared with a 6-month pre-implementation group (February 2021 to July 2021). CTCA was recommended first-line in suspected stable cardiac chest pain, followed by chest pain clinic review. Predefined criteria were provided recommending functional testing in select patients. The impact of CTCA versus functional testing was evaluated. Data were obtained from digital medical records. RESULTS Three hundred and fifteen patients were included, 143 pre-implementation and 172 post-implementation. Characteristics were similar except age (pre-implementation: 58.9 ± 12.0 vs post-implementation: 62.8 ± 12.3 years, P = 0.004). Pathway-guided management resulted in higher first-line CTCA (73.3% vs 46.2%, P < 0.001), lower functional testing (30.2% vs 56.6%, P < 0.001) and lower proportion undergoing two non-invasive tests (4.7% vs 10.5%, P = 0.047), without increasing investigation costs or invasive coronary angiography (ICA) (pre-implementation: 13.3% vs post-implementation: 9.3%, P = 0.263). In patients undergoing CTCA, 40.7% had normal coronaries and 36.2% minimal/mild disease, with no difference in disease burden post-implementation. More medication changes occurred following CTCA compared with functional testing (aspirin: P = 0.005, statin: P < 0.001). In patients undergoing ICA, revascularisation to ICA ratio was higher following CTCA compared with functional testing (91.7% vs 18.2%, P < 0.001). No 30-day myocardial infarction or death occurred. CONCLUSIONS The pathway increased CTCA utilisation and reduced downstream investigations. CTCA was associated with medication changes and improved ICA efficiency.
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Affiliation(s)
- Nick S R Lan
- Department of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
- Medical School, Harry Perkins Institute of Medical Research, The University of Western Australia, Perth, Western Australia, Australia
| | - David-Raj Thomas
- Department of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Christopher L Jones
- Department of Emergency Medicine, Fiona Stanley Hospital, Perth, Western Australia, Australia
- School of Medicine, The University of Notre Dame Australia, Fremantle, Western Australia, Australia
| | - Vikram Raju
- Department of Radiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Jeanette Soon
- Department of Radiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Jacobus Otto
- Department of Radiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Chris Wood
- Department of Radiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Tom Briffa
- School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Girish Dwivedi
- Department of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
- Medical School, Harry Perkins Institute of Medical Research, The University of Western Australia, Perth, Western Australia, Australia
| | - James M Rankin
- Department of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Abdul Rahman Ihdayhid
- Department of Cardiology, Fiona Stanley Hospital, Perth, Western Australia, Australia
- Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia
- Curtin Medical School, Curtin University, Perth, Western Australia, Australia
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3
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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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4
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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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5
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Lee KK, Lowe D, O'Brien R, Wereski R, Bularga A, Taggart C, Lowry MTH, Ferry AV, Williams MC, Roditi G, Byrne J, Tuck C, Cranley D, Thokala P, Goodacre S, Keerie C, Norrie J, Newby DE, Gray AJ, Mills NL. Troponin in acute chest pain to risk stratify and guide effective use of computed tomography coronary angiography (TARGET-CTCA): a randomised controlled trial. Trials 2023; 24:402. [PMID: 37312104 PMCID: PMC10264092 DOI: 10.1186/s13063-023-07431-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 06/05/2023] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND The majority of patients with suspected acute coronary syndrome presenting to the emergency department will be discharged once myocardial infarction has been ruled out, although a proportion will have unrecognised coronary artery disease. In this setting, high-sensitivity cardiac troponin identifies those at increased risk of future cardiac events. In patients with intermediate cardiac troponin concentrations in whom myocardial infarction has been ruled out, this trial aims to investigate whether outpatient computed tomography coronary angiography (CTCA) reduces subsequent myocardial infarction or cardiac death. METHODS TARGET-CTCA is a multicentre prospective randomised open label with blinded endpoint parallel group event driven trial. After myocardial infarction and clear alternative diagnoses have been ruled out, participants with intermediate cardiac troponin concentrations (5 ng/L to 99th centile upper reference limit) will be randomised 1:1 to outpatient CTCA plus standard of care or standard of care alone. The primary endpoint is myocardial infarction or cardiac death. Secondary endpoints include clinical, patient-centred, process and cost-effectiveness. Recruitment of 2270 patients will give 90% power with a two-sided P value of 0.05 to detect a 40% relative risk reduction in the primary endpoint. Follow-up will continue until 97 primary outcome events have been accrued in the standard care arm with an estimated median follow-up of 36 months. DISCUSSION This randomised controlled trial will determine whether high-sensitivity cardiac troponin-guided CTCA can improve outcomes and reduce subsequent major adverse cardiac events in patients presenting to the emergency department who do not have myocardial infarction. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03952351. Registered on May 16, 2019.
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Affiliation(s)
- Kuan Ken Lee
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, EH16 4SA, UK
| | - David Lowe
- Department of Emergency Medicine, Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Rachel O'Brien
- Department of Emergency Medicine, Emergency Medicine Research Group, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Ryan Wereski
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, EH16 4SA, UK
| | - Anda Bularga
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, EH16 4SA, UK
| | - Caelan Taggart
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, EH16 4SA, UK
| | - Matthew T H Lowry
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, EH16 4SA, UK
| | - Amy V Ferry
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, EH16 4SA, UK
| | - Michelle C Williams
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, EH16 4SA, UK
| | - Giles Roditi
- Institute of Cardiovascular and Medical Sciences, Glasgow University, Glasgow, UK
| | - John Byrne
- Department of Cardiology, Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Chris Tuck
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, EH16 4SA, UK
| | - Denise Cranley
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Praveen Thokala
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Steve Goodacre
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Catriona Keerie
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - John Norrie
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - David E Newby
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, EH16 4SA, UK
| | - Alasdair J Gray
- Department of Emergency Medicine, Emergency Medicine Research Group, Royal Infirmary of Edinburgh, Edinburgh, UK
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, EH16 4SA, UK.
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.
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6
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Kumar K, Seetharam K, Rani T, Mir P, Mir T, Shetty V, Shani J. Evolution of Stress Echocardiogram in the Era of CT Angiography. Cureus 2023; 15:e39501. [PMID: 37378169 PMCID: PMC10292127 DOI: 10.7759/cureus.39501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/21/2023] [Indexed: 06/29/2023] Open
Abstract
The ideal diagnostic modality for acute chest pain is a highly debated topic in the cardiovascular community. With the rapid rise of coronary computed tomography angiography (CTA) and the fall of functional testing, stress echocardiography (SE) is at a delicate crossroads. Though there are many advantages of coronary CTA, it is not without its flaws. The exact realm of SE needs to be clearly defined, as well as which patients need diagnostic testing. The emergence of additional parameters will propel the evolution of modern SE. In this review article, we explore the role of SE, guidelines, comparison of SE versus CTA, and additional parameters in the coronary CTA era.
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Affiliation(s)
- Kelash Kumar
- Internal Medicine, Maimonides Medical Center, New York, USA
| | | | - Teesha Rani
- Medicine and Surgery, Ziauddin University, Karachi, PAK
| | - Parvez Mir
- Internal Medicine and Pulmonology, Wyckoff Heights Medical Center, New York, USA
| | - Tanveer Mir
- Internal Medicine, Wyckoff Heights Medical Center, New York, USA
| | - Vijay Shetty
- Internal Medicine and Cardiology, Maimonides Medical Center, New York, USA
| | - Jacob Shani
- Cardiology, Maimonides Medical Center, New York, USA
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7
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Garg Y, Seetharam K, Sharma M, Rohita DK, Nabi W. Role of Deep Learning in Computed Tomography. Cureus 2023; 15:e39160. [PMID: 37332431 PMCID: PMC10275744 DOI: 10.7759/cureus.39160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2023] [Indexed: 06/20/2023] Open
Abstract
Computed tomography has played an instrumental role in the understanding of the pathophysiology of atherosclerosis in coronary artery disease. It enables visualization of the plaque obstruction and vessel stenosis in a comprehensive manner. As technology for computed tomography is constantly evolving, coronary applications and possibilities are constantly expanding. This influx of information can overwhelm a physician's ability to interpret information in this era of big data. Machine learning is a revolutionary approach that can help provide limitless pathways in patient management. Within these machine algorithms, deep learning has tremendous potential and can revolutionize computed tomography and cardiovascular imaging. In this review article, we highlight the role of deep learning in various aspects of computed tomography.
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Affiliation(s)
- Yash Garg
- Internal Medicine, Wyckoff Heights Medical Center, New York, USA
| | | | - Manjari Sharma
- Internal Medicine, Wyckoff Heights Medical Center, New York, USA
| | - Dipesh K Rohita
- Internal Medicine, Wyckoff Heights Medical Center, New York, USA
| | - Waseem Nabi
- Internal Medicine, Wyckoff Heights Medical Center, New York, USA
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8
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Qasum M, Massalha S, Marcusohn E, Elias A, Darawshi S, Zukermann R. Coronary computed tomography angiography in the evaluation of acute chest pain in patients with elevated high sensitive cardiac troponin I (hs-cTn) level. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2023; 27:100276. [PMID: 38511099 PMCID: PMC10945961 DOI: 10.1016/j.ahjo.2023.100276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 02/13/2023] [Accepted: 02/13/2023] [Indexed: 03/22/2024]
Abstract
Aims CCTA is a well-established and safe imaging modality for the diagnosis of CAD and is gate keeping for invasive coronary angiography (ICA). We aimed to examine CCTA performance in patients presenting with ACP and dynamic hs-cTn elevation compatible with MI but not exceeding 7 folds of the URL. We also examined the performance of GRACE and PTP consortium scores in this population of patients.
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Affiliation(s)
- Majd Qasum
- Departments of Cardiology, Rambam Health Care Campus, Haifa, Israel
- Department of Nuclear Medicine, Rambam Health Care Campus, Haifa, Israel
| | - Samia Massalha
- Departments of Cardiology, Rambam Health Care Campus, Haifa, Israel
- Department of Nuclear Medicine, Rambam Health Care Campus, Haifa, Israel
| | - Erez Marcusohn
- Departments of Cardiology, Rambam Health Care Campus, Haifa, Israel
| | - Adi Elias
- Departments of Cardiology, Rambam Health Care Campus, Haifa, Israel
| | - Said Darawshi
- Department of Medicine D, Ruth & Bruce Rappaport Faculty of Medicine, Rambam Health Care Campus, Technion-IIT, Haifa, Israel
| | - Robert Zukermann
- Departments of Cardiology, Rambam Health Care Campus, Haifa, Israel
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9
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Ihdayhid AR, Lan NSR, Figtree GA, Patel S, Arnott C, Hamilton-Craig C, Psaltis PJ, Leipsic J, Fairbairn T, Wahi S, Hillis GS, Rankin JM, Dwivedi G, Nicholls SJ. Contemporary Chest Pain Evaluation: The Australian Case for Cardiac CT. Heart Lung Circ 2023; 32:297-306. [PMID: 36610819 DOI: 10.1016/j.hlc.2022.12.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 10/07/2022] [Accepted: 12/06/2022] [Indexed: 01/07/2023]
Abstract
Computed tomography coronary angiography (CTCA) is a non-invasive diagnostic modality that provides a comprehensive anatomical assessment of the coronary arteries and coronary atherosclerosis, including plaque burden, composition and morphology. The past decade has witnessed an increase in the role of CTCA for evaluating patients with both stable and acute chest pain, and recent international guidelines have provided increasing support for a first line CTCA diagnostic strategy in select patients. CTCA offers some advantages over current functional tests in the detection of obstructive and non-obstructive coronary artery disease, as well as for ruling out obstructive coronary artery disease. Recent randomised trials have also shown that CTCA improves prognostication and guides the use of guideline-directed preventive therapies, leading to improved clinical outcomes. CTCA technology advances such as fractional flow reserve, plaque quantification and perivascular fat inflammation potentially allow for more personalised risk assessment and targeted therapies. Further studies evaluating demand, supply, and cost-effectiveness of CTCA for evaluating chest pain are required in Australia. This discussion paper revisits the evidence supporting the use of CTCA, provides an overview of its implications and limitations, and considers its potential role for chest pain evaluation pathways in Australia.
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Affiliation(s)
- Abdul Rahman Ihdayhid
- Department of Cardiology, Fiona Stanley Hospital, Perth, WA, Australia; Harry Perkins Institute of Medical Research, Curtin University, Perth, WA, Australia.
| | - Nick S R Lan
- Department of Cardiology, Fiona Stanley Hospital, Perth, WA, Australia; Harry Perkins Institute of Medical Research, University of Western Australia, Perth, WA, Australia
| | - Gemma A Figtree
- Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia; Kolling Institute of Medical Research, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Sanjay Patel
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Clare Arnott
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, NSW, Australia; Cardiovascular Division, The George Institute for Global Health, Sydney, NSW, Australia
| | | | - Peter J Psaltis
- Department of Cardiology, Royal Adelaide Hospital, Central Adelaide Local Health Network, Adelaide, SA, Australia
| | - Jonathon Leipsic
- University of British Columbia, St Paul's Hospital, Vancouver, Canada
| | | | - Sudhir Wahi
- Princess Alexandra Hospital, University of Queensland, Brisbane, Qld, Australia
| | - Graham S Hillis
- Department of Cardiology and University of Western Australia, Royal Perth Hospital, Perth, WA, Australia
| | - James M Rankin
- Department of Cardiology, Fiona Stanley Hospital, Perth, WA, Australia
| | - Girish Dwivedi
- Department of Cardiology, Fiona Stanley Hospital, Perth, WA, Australia; Harry Perkins Institute of Medical Research, University of Western Australia, Perth, WA, Australia
| | - Stephen J Nicholls
- Monash Cardiovascular Research Centre, Victorian Heart Institute, Monash University, Melbourne, Vic, Australia
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10
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Affiliation(s)
- Charlotte Greer
- Christchurch Heart Institute, University of Otago, Christchurch, New Zealand
| | - David E Newby
- Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK
| | - Philip D Adamson
- Christchurch Heart Institute, University of Otago, Christchurch, New Zealand .,Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK
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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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Galea N, Bellu R, Catapano F, Marchitelli L, Cannavale G, Sedati P, Colmo C, Zamana A, Arboit M, Raspanti X, Roncacci A, Catalano C, Francone M. Coronary Computed Tomography Angiography in acute chest pain: a sustainable model with remote support. Eur J Radiol 2022; 151:110277. [DOI: 10.1016/j.ejrad.2022.110277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 02/20/2022] [Accepted: 03/20/2022] [Indexed: 11/30/2022]
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Pontone G, Rossi A, Guglielmo M, Dweck MR, Gaemperli O, Nieman K, Pugliese F, Maurovich-Horvat P, Gimelli A, Cosyns B, Achenbach S. Clinical applications of cardiac computed tomography: a consensus paper of the European Association of Cardiovascular Imaging-part I. Eur Heart J Cardiovasc Imaging 2022; 23:299-314. [PMID: 35076061 PMCID: PMC8863074 DOI: 10.1093/ehjci/jeab293] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 12/14/2021] [Indexed: 01/26/2023] Open
Abstract
Cardiac computed tomography (CT) was introduced in the late 1990's. Since then, an increasing body of evidence on its clinical applications has rapidly emerged. From an initial emphasis on its technical efficiency and diagnostic accuracy, research around cardiac CT has now evolved towards outcomes-based studies that provide information on prognosis, safety, and cost. Thanks to the strong and compelling data generated by large, randomized control trials, the scientific societies have endorsed cardiac CT as pivotal diagnostic test for the management of appropriately selected patients with acute and chronic coronary syndrome. This consensus document endorsed by the European Association of Cardiovascular Imaging is divided into two parts and aims to provide a summary of the current evidence and to give updated indications on the appropriate use of cardiac CT in different clinical scenarios. This first part focuses on the most established applications of cardiac CT from primary prevention in asymptomatic patients, to the evaluation of patients with chronic coronary syndrome, acute chest pain, and previous coronary revascularization.
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Affiliation(s)
- Gianluca Pontone
- Centro Cardiologico Monzino IRCCS, Via C. Parea 4, 20138 Milan, Italy
| | - Alexia Rossi
- Department of Nuclear Medicine, University Hospital, Zurich, Switzerland
- Center for Molecular Cardiology, University of Zurich, Zurich, Switzerland
| | - Marco Guglielmo
- Centro Cardiologico Monzino IRCCS, Via C. Parea 4, 20138 Milan, Italy
| | - Marc R Dweck
- Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK
| | | | - Koen Nieman
- Department of Radiology and Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Francesca Pugliese
- Department of Cardiology, Barts Heart Centre, Barts Health NHS Trust, London, UK
- Centre for Cardiovascular Medicine and Devices, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Pal Maurovich-Horvat
- MTA-SE Cardiovascular Imaging Research Group, Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Alessia Gimelli
- Fondazione CNR/Regione Toscana “Gabriele Monasterio”, Pisa, Italy
| | - Bernard Cosyns
- Department of Cardiology, CHVZ (Centrum voor Hart en Vaatziekten), ICMI (In Vivo Cellular and Molecular Imaging) Laboratory, Universitair ziekenhuis Brussel, Brussel, Belgium
| | - Stephan Achenbach
- Department of Cardiology, Friedrich-Alexander-University of Erlangen, Erlangen, Germany
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Lee KK, Bularga A, O'Brien R, Ferry AV, Doudesis D, Fujisawa T, Kelly S, Stewart S, Wereski R, Cranley D, van Beek EJR, Lowe DJ, Newby DE, Williams MC, Gray AJ, Mills NL. Troponin-Guided Coronary Computed Tomographic Angiography After Exclusion of Myocardial Infarction. J Am Coll Cardiol 2021; 78:1407-1417. [PMID: 34593122 PMCID: PMC8482793 DOI: 10.1016/j.jacc.2021.07.055] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 07/28/2021] [Accepted: 07/29/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Patients with suspected acute coronary syndrome in whom myocardial infarction has been excluded are at risk of future adverse cardiac events. OBJECTIVES This study evaluated the usefulness of high-sensitivity cardiac troponin I (hs-cTnI) to select patients for further investigation after myocardial infarction has been excluded. METHODS This is a prospective cohort study of patients presenting to the emergency department with suspected acute coronary syndrome and hs-cTnI concentrations below the sex-specific 99th percentile. Patients were recruited in a 2:1 fashion, stratified by peak hs-cTnI concentration above and below the risk stratification threshold of 5 ng/L. All patients underwent coronary computed tomography angiography (CCTA) after hospital discharge. RESULTS Overall, 250 patients were recruited (61.4 ± 12.2 years 31% women) in whom 62.4% (156 of 250 patients) had coronary artery disease (CAD). Patients with intermediate hs-cTnI concentrations (between 5 ng/L and the sex-specific 99th percentile) were more likely to have CAD than those with hs-cTnI concentrations <5 ng/L (71.9% [120 of 167 patients] vs 43.4% [36 of 83 patients]; odds ratio: 3.33; 95% CI: 1.92-5.78). Conversely, there was no association between anginal symptoms and CAD (63.2% [67 of 106 patients] vs 61.8% [89 of 144 patients]; odds ratio: 0.92; 95% CI: 0.48-1.76). Most patients with CAD did not have a previous diagnosis (53.2%; 83 of 156 patients) and were not on antiplatelet and statin therapies (63.5%; 99 of 156 patients) before they underwent CCTA. CONCLUSIONS In patients who had myocardial infarction excluded, CAD was 3× more likely in those with intermediate hs-cTnI concentrations compared with low hs-cTnI concentrations. In such patients, CCTA could help to identify those with occult CAD and to target preventative treatments, thereby improving clinical outcomes.
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Affiliation(s)
- Kuan Ken Lee
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Anda Bularga
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Rachel O'Brien
- Department of Emergency Medicine, Emergency Medicine Research Group, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Amy V Ferry
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Dimitrios Doudesis
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
| | - Takeshi Fujisawa
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Shauna Kelly
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Stacey Stewart
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Ryan Wereski
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Denise Cranley
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Edwin J R van Beek
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Edinburgh Imaging Facility QMRI (The Queen's Medical Research Institute), University of Edinburgh, Edinburgh, United Kingdom
| | - David J Lowe
- University of Glasgow, School of Medicine, Glasgow, United Kingdom
| | - David E Newby
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Michelle C Williams
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Edinburgh Imaging Facility QMRI (The Queen's Medical Research Institute), University of Edinburgh, Edinburgh, United Kingdom
| | - Alasdair J Gray
- Department of Emergency Medicine, Emergency Medicine Research Group, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom; Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
| | - Nicholas L Mills
- BHF Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom; Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom.
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15
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Computed tomography of coronary artery atherosclerosis: A review. J Med Imaging Radiat Sci 2021; 52:S19-S39. [PMID: 34479831 DOI: 10.1016/j.jmir.2021.08.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 07/29/2021] [Accepted: 08/06/2021] [Indexed: 11/23/2022]
Abstract
Coronary artery atherosclerosis resulting in ischemic cardiac disease is the leading cause of mortality in the United States. In symptomatic patients, invasive diagnostic methods like catheter angiography, intravascular ultrasound, or vascular endoscopy may be used. However, for primary prevention of atherosclerotic coronary artery disease in asymptomatic patients, non-invasive methods are more commonly utilized like stress imaging, single-photon emission computed tomography (SPECT) and coronary artery calcification scoring. Coronary computed tomographic angiography (CCTA) is an excellent diagnostic tool for detection of coronary artery plaque and ability to identify resultant stenoses with an excellent negative predictive value which can potentially result in optimal exclusion of the presence of coronary artery disease. Long term follow up after a negative CCTA has repeatedly demonstrated very low incidence of future adverse coronary events, attesting its predictive value. CCTA based management is associated with improved CAD outcome in stable angina. Coronary CTA is valuable in acute chest pain evaluation in the emergency department helping in better triage. CT perfusion and CT-FFR are both very promising tools for assessment of hemodynamic significance of coronary artery stenosis.
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16
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Sörensson P, Dellborg M, Börjesson M. The role of modern cardiovascular imaging in (suspected) coronary artery disease in competitive athletes. Trends Cardiovasc Med 2021; 32:431-437. [PMID: 34481978 DOI: 10.1016/j.tcm.2021.08.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 08/28/2021] [Accepted: 08/29/2021] [Indexed: 01/09/2023]
Abstract
This overview addresses different non-invasive imaging methods in diagnosing CAD before clearing the athlete for participation in sports activity. Keep in mind the risks and benefits of exercising for the competitive athlete and to use the SCORE-information as a first evaluation tool. It is essential to gather relevant information and to complement anatomical evaluations with functional evaluations. Exercise testing also has an added value in athletes as it will inform both the physician and the athlete on the aerobic fitness of the individual, a key factor in risk assessment.
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Affiliation(s)
- P Sörensson
- Karolinska Institutet, Department of Medicine, Solna, Sweden; Cardiac MRI, Adult Congenital Heart Disease, Karolinska University Hospital, Stockholm, Sweden.
| | - M Dellborg
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden; Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden.
| | - M Börjesson
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden; Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden; Center for Health and Performance, Gothenburg University, Gothenburg, Sweden..
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17
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Madanchi M, Cioffi GM, Kobza R, Cuculi F, Bossard M. The Importance of Defining the Coronary Anatomy in Suspected Myopericarditis: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e929009. [PMID: 33780431 PMCID: PMC8019837 DOI: 10.12659/ajcr.929009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 02/21/2021] [Accepted: 01/14/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND It is challenging to distinguish between acute coronary syndrome (ACS) and myocardial injury due to alternative causes (eg myopericarditis, coronary vasospasm, and pulmonary embolism), as they often share similar presentations, especially in young patients. Coronary computerized tomography angiography (CCTA) is increasingly recognized as a fast and safe diagnostic tool for rapid assessment of the coronary anatomy among patients with a low to intermediate cardiovascular risk profile and/or atypical chest pain. However, its utility among patients with possible ACS is still debated. CASE REPORT A 36-year-old man presented to our institution with intermittent pleuritic chest pain and malaise over the preceding 7 days. He was a smoker and his father had ACS at the age of 45 years. The patient had unspecific electrocardiographic changes and elevated troponin values. The initial transthoracic echocardiogram indicated a normal ejection fraction without any wall motion abnormalities. Presuming a very low chance of coronary artery disease due to his age and atypical symptoms, we ordered a CCTA, which identified a thrombotic lesion in the right coronary artery (RCA). An invasive coronary angiography, including an optical coherence tomography, confirmed the presence of a thrombotic lesion located at the level of the proximal RCA, which was consequently treated with 1 drug-eluting stent. CONCLUSIONS Physicians should always eliminate underlying coronary artery disease among patients with unclear myocardial injury, irrespective of a patient's presentation, age, and estimated cardiovascular risk. In this context, CCTA represents a safe and simple tool to rapidly assess the coronary anatomy, especially in younger patients.
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18
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Seitun S, Clemente A, Maffei E, Toia P, La Grutta L, Cademartiri F. Prognostic value of cardiac CT. Radiol Med 2020; 125:1135-1147. [PMID: 33047297 DOI: 10.1007/s11547-020-01285-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 09/03/2020] [Indexed: 11/28/2022]
Abstract
In the past decades, coronary computed tomography angiography (CCTA) has become a powerful tool in the management of coronary artery disease. The diagnostic and prognostic value of CCTA has been extensively demonstrated in both large observational studies and clinical trials among stable chest pain patients. The quantification of coronary artery calcium score (CACS) is a well-established predictor of cardiovascular morbidity and mortality in asymptomatic subjects. Besides CACS, the main strength of CCTA is the accurate assessment of the individual total atherosclerotic plaque burden, which holds important prognostic information. In addition, CCTA, by providing detailed information on coronary plaque morphology and composition with identification of specific high-risk plaque features, may further improve the risk stratification beyond the assessment of coronary stenosis. The development of new CCTA applications, such as stress myocardial CT perfusion and computational fluids dynamic applied to standard CCTA to derive CT-based fractional flow reserve (FFR) values have shown promising results to guide revascularization, potentially improving clinical outcomes in stable chest pain patients. In this review, starting from the role of CACS and moving beyond coronary stenosis, we evaluate the existing evidence of the prognostic effectiveness of the CCTA strategy in real-world clinical practice.
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Affiliation(s)
- Sara Seitun
- Department of Radiology, IRCCS Policlinico San Martino Hospital, Genoa, Italy
| | - Alberto Clemente
- Department of Radiology, CNR (National Council of Research)/Tuscany Region 'Gabriele Monasterio' Foundation (FTGM), Massa, Italy
| | - Erica Maffei
- Department of Radiology - Area Vasta 1 - ASUR Marche, Ospedale Civile "Santa Maria della Misericordia" di Urbino, Viale Federico Comandino, 70, 61029, Urbino, PU, Italy
| | - Patrizia Toia
- Department of Radiology, DIBIMED, University of Palermo, Palermo, Italy
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Mansour HH, Alajerami YS, Najim AA. Coronary computed tomography angiography versus invasive coronary angiography: medical staff perceptions and diagnostic interest in Gaza-Palestine. Ir J Med Sci 2020; 190:567-575. [PMID: 32978639 DOI: 10.1007/s11845-020-02376-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 09/22/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Invasive coronary angiography (ICA) and coronary computed tomography angiography (CCTA) are used in the diagnosis of coronary artery disease (CAD). The medical benefits, as well as the ethical and logistical implications, should be explored, particularly in the scarcity of medical resources. We explore the perception of medical staff toward the interest of CCTA and ICA in diagnosis CAD to maximize the utility of both procedures. METHODS A triangulated observational, analytical prospective cohort study carried out among patients suspected with CAD who underwent CCTA and ICA. The quantitative part included 381 patients (250 underwent ICA and 131 underwent CCTA). The qualitative part included a purposive sample of two radiologists, three cardiologists, and two medical imaging specialists. RESULTS Low diagnostic yield of the ICA through 31.3% and 39.7% diagnosed without CAD and non-significant CAD, respectively. Risk factors such as the family history of heart disease, obesity, high cholesterol, and diabetes were with high frequency in the patients with significant CAD. The sensitivity, specificity, PPV, and NPV of CCTA technique was 94.74%, 94.23%, 92.31%, and 96.08% respectively. Cardiologist's perceptions focused on radiation concerns and difficulties for convincing patients to perform the CCTA procedure. Radiologists and medical imaging specialists focused on complete cooperation from the cardiologist to better preparation of patients to perform optimal CCTA procedures. CONCLUSION Efficient diagnostic benefits of CCTA and overuse of ICA for stable CAD are documented. Clear diagnostic strategy with medical, ethical, and logistical issues should be considered when selecting the CCTA or ICA for diagnosis CAD.
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Affiliation(s)
- Husam H Mansour
- Radiology Department, Al-Shifa Hospital, Gaza, Palestine. .,Medical Imaging Department, Al-Azhar University, Gaza, Palestine.
| | | | - Ahmed A Najim
- Nursing Department, Al-Azhar University, Gaza, Palestine
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Shaw L, Kwong RY, Nagel E, Salerno M, Jaffer F, Blankstein R, Dilsizian V, Flachskampf F, Grayburn P, Leipsic J, Marwick T, Nieman K, Raman S, Sengupta P, Zoghbi W, Pellikka PA, Swaminathan M, Dorbala S, Thompson R, Al-Mallah M, Calnon D, Polk D, Soman P, Beanlands R, Garrett KN, Henry TD, Rao SV, Duffy PL, Cox D, Grines C, Mahmud E, Bucciarelli-Ducci C, Plein S, Greenwood JP, Berry C, Carr J, Arai AE, Murthy VL, Ruddy TD, Chandrashekhar Y. Cardiac Imaging in the Post-ISCHEMIA Trial Era. JACC Cardiovasc Imaging 2020; 13:1815-1833. [DOI: 10.1016/j.jcmg.2020.05.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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21
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Goehler A, Mayrhofer T, Pursnani A, Ferencik M, Lumish HS, Barth C, Karády J, Chow B, Truong QA, Udelson JE, Fleg JL, Nagurney JT, Gazelle GS, Hoffmann U. Long-term health outcomes and cost-effectiveness of coronary CT angiography in patients with suspicion for acute coronary syndrome. J Cardiovasc Comput Tomogr 2020; 14:44-54. [PMID: 31303580 PMCID: PMC6930365 DOI: 10.1016/j.jcct.2019.06.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 04/11/2019] [Accepted: 06/10/2019] [Indexed: 02/01/2023]
Abstract
BACKGROUND Randomized trials have shown favorable clinical outcomes for coronary CT angiography (CTA) in patients with suspected acute coronary syndrome (ACS). Our goal was to estimate the cost-effectiveness of coronary CTA as compared to alternative management strategies for ACP patients over lifetime. METHODS Markov microsimulation model was developed to compare cost-effectiveness of competitive strategies for ACP patients: 1) coronary CTA, 2) standard of care (SOC), 3) AHA/ACC Guidelines, and 4) expedited emergency department (ED) discharge protocol with outpatient testing. ROMICAT-II trial was used to populate the model with low to intermediate risk of ACS patient data, whereas diagnostic test-, treatment effect-, morbidity/mortality-, quality of life- and cost data were obtained from the literature. We predicted test utilization, costs, 1-, 3-, 10-year and over lifetime cardiovascular morbidity/mortality for each strategy. We determined quality adjusted life years (QALY) and incremental cost-effectiveness ratio. Observed outcomes in ROMICAT-II were used to validate the short-term model. RESULTS Estimated short-term outcomes accurately reflected observed outcomes in ROMICAT-II as coronary CTA was associated with higher costs ($4,490 vs. $2,513-$4,144) and revascularization rates (5.2% vs. 2.6%-3.7%) compared to alternative strategies. Over lifetime, coronary CTA dominated SOC and ACC/AHA Guidelines and was cost-effective compared to expedited ED protocol ($49,428/QALY). This was driven by lower cardiovascular mortality (coronary CTA vs. expedited discharge: 3-year: 1.04% vs. 1.10-1.17; 10-year: 5.06% vs. 5.21-5.36%; respectively). CONCLUSION Coronary CTA in patients with suspected ACS renders affordable long-term health benefits as compared to alternative strategies.
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Affiliation(s)
- Alexander Goehler
- Division of Abdominal Imaging and Intervention, Department of Radiology, Brigham and Women's Hospital, Boston, MA, USA; Cardiac MR PET CT Program, Massachusetts General Hospital, Department of Radiology, Boston, MA, USA; Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Thomas Mayrhofer
- Cardiac MR PET CT Program, Massachusetts General Hospital, Department of Radiology, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; School of Business Studies, Stralsund University of Applied Sciences, Stralsund, Germany
| | - Amit Pursnani
- Cardiology Division, Evanston Hospital, Walgreen Building 3rd Floor, 2650, Ridge Ave, Evanston, IL, USA
| | - Maros Ferencik
- Cardiac MR PET CT Program, Massachusetts General Hospital, Department of Radiology, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Knight Cardiovascular Institute, Oregon Health and Science University, 3180, SW Sam Jackson Park Rd., Portland, OR, USA
| | - Heidi S Lumish
- Cardiac MR PET CT Program, Massachusetts General Hospital, Department of Radiology, Boston, MA, USA
| | - Cordula Barth
- Cardiac MR PET CT Program, Massachusetts General Hospital, Department of Radiology, Boston, MA, USA
| | - Júlia Karády
- Cardiac MR PET CT Program, Massachusetts General Hospital, Department of Radiology, Boston, MA, USA; MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Benjamin Chow
- University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Ontario, Canada
| | - Quynh A Truong
- Department of Radiology, New York Presbyterian Hospital and Weill Cornell Medicine, New York, NY, USA
| | - James E Udelson
- Division of Cardiology, Tufts New England Medical Center, Boston, MA, USA
| | - Jerome L Fleg
- National Heart, Lung, and Blood Institute, Bethesda, MD, USA
| | - John T Nagurney
- Harvard Medical School, Boston, MA, USA; Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - G Scott Gazelle
- Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA; Department of Health Management and Policy, Harvard School of Public Health, Boston, MA, USA
| | - Udo Hoffmann
- Cardiac MR PET CT Program, Massachusetts General Hospital, Department of Radiology, Boston, MA, USA; Harvard Medical School, Boston, MA, USA.
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Adamson PD, Than MP. CT coronary angiography does not reduce mortality or myocardial infarction in low-risk patients with acute chest pain. BMJ Evid Based Med 2019; 24:e5. [PMID: 30396886 DOI: 10.1136/bmjebm-2018-111090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/08/2018] [Indexed: 11/04/2022]
Affiliation(s)
- Philip D Adamson
- BHF Centre for Cardiovascular Research, University of Edinburgh, Edinburgh, UK
- Christchurch Heart Institute, University of Otago, Christchurch, New Zealand
| | - Martin P Than
- Emergency Department, Christchurch Hospital, Christchurch, New Zealand
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Williams MC, Newby DE, Nicol ED. Coronary atherosclerosis imaging by CT to improve clinical outcomes. J Cardiovasc Comput Tomogr 2019; 13:281-287. [PMID: 30952611 PMCID: PMC6928571 DOI: 10.1016/j.jcct.2019.03.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 02/13/2019] [Accepted: 03/25/2019] [Indexed: 01/13/2023]
Abstract
Coronary artery disease remains an important cause of morbidity and mortality world-wide. Coronary Computed Tomography Angiography (CCTA) has excellent diagnostic accuracy and the identification and stratification of coronary artery disease is associated with improved prognosis in multiple studies. Recent randomized controlled trials have shown that in patients with stable coronary artery disease, CCTA is associated with improved diagnosis, changes in investigations, changes in medical treatment and appropriate selection for revascularization. Importantly this diagnostic approach reduces the long-term risk of fatal and non-fatal myocardial infarction. The identification of adverse plaques on CCTA is known to be associated with an increased risk of acute coronary syndrome, but does not appear to be predictive of long-term outcomes independent of coronary artery calcium burden. Future research will involve the assessment of outcomes after CCTA in patients with acute chest pain and asymptomatic patients. In addition, more advanced quantification of plaque subtypes, vascular inflammation and coronary flow dynamics may identify further patients at increased risk.
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Affiliation(s)
- Michelle C Williams
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Edinburgh, UK; Edinburgh Imaging Facility QMRI, University of Edinburgh, Edinburgh, UK.
| | - David E Newby
- University of Edinburgh/British Heart Foundation Centre for Cardiovascular Science, Edinburgh, UK; Edinburgh Imaging Facility QMRI, University of Edinburgh, Edinburgh, UK
| | - Edward D Nicol
- Royal Brompton and Harefield NHS Foundation Trust Departments of Cardiology and Radiology, London, UK; National Heart and Lung Institute, Faculty of Medicine, Imperial College, London, UK
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The role of coronary CT angiography for acute chest pain in the era of high-sensitivity troponins. J Cardiovasc Comput Tomogr 2019; 13:267-273. [PMID: 31235403 DOI: 10.1016/j.jcct.2019.05.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 05/01/2019] [Accepted: 05/02/2019] [Indexed: 11/22/2022]
Abstract
Accurate and efficient diagnostic triage for acute chest pain (ACP) remains one of the most challenging problems in the emergency department (ED). While the proportion of patients that present with myocardial infarction (MI), aortic dissection, or pulmonary embolism is relatively low, a missed diagnosis can be life threatening. Coronary computed tomography angiography (CCTA) has developed into a robust diagnostic tool in the triage of ACP over the past decade, with several trials showing that it can reliably identify patients at low risk of major adverse cardiovascular events, shorten the length of stay in the ED, and reduce cost associated with the triage of patients with undifferentiated chest pain. Recently, however, high-sensitivity troponin assays have been increasingly incorporated as a rapid and efficient diagnostic test in the triage of ACP due to their higher sensitivity and negative predictive value of myocardial infarction. As more EDs adopt high-sensitivity troponin assays into routine clinical practice, the role of CCTA will likely change. In this review, we provide an overview of CCTA and high-sensitivity troponins for evaluation of patients with suspected ACS in the ED. Moreover, we discuss the changing role of CCTA in the era of high-sensitivity troponins.
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Tzolos E, Newby DE. Coronary Computed Tomography Angiography Improving Outcomes in Patients with Chest Pain. CURRENT CARDIOVASCULAR IMAGING REPORTS 2019; 12:15. [PMID: 33442442 PMCID: PMC7116579 DOI: 10.1007/s12410-019-9492-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Purpose of Review To provide an overview of recent studies of coronary computed tomography angiography (CCTA) and how it has helped to improve clinical outcomes for patients presenting with chest pain. Recent Findings Randomised controlled trials have uniformly demonstrated that the use of CCTA is associated with improvements in patient diagnosis, management and treatments as well as the avoidance of unnecessary invasive coronary angiography. These changes have been associated with consistent reductions in long-term rates of fatal or non-fatal myocardial infarction. Summary Major beneficial effects in clinical management and patient outcomes are seen with the use of coronary computed tomography angiography. CCTA might be considered to be the first test of choice for the investigation of coronary heart disease.
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Affiliation(s)
- Evangelos Tzolos
- British Heart Foundation, Centre for Cardiovascular Science, University of Edinburgh, Chancellor’s Building, Edinburgh EH16 4SA, Scotland, UK
| | - David E. Newby
- British Heart Foundation, Centre for Cardiovascular Science, University of Edinburgh, Chancellor’s Building, Edinburgh EH16 4SA, Scotland, UK
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Newby DE, Adamson PD, Berry C, Boon NA, Dweck MR, Flather M, Forbes J, Hunter A, Lewis S, MacLean S, Mills NL, Norrie J, Roditi G, Shah ASV, Timmis AD, van Beek EJR, Williams MC. Coronary CT Angiography and 5-Year Risk of Myocardial Infarction. N Engl J Med 2018; 379:924-933. [PMID: 30145934 DOI: 10.1056/nejmoa1805971] [Citation(s) in RCA: 830] [Impact Index Per Article: 138.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Although coronary computed tomographic angiography (CTA) improves diagnostic certainty in the assessment of patients with stable chest pain, its effect on 5-year clinical outcomes is unknown. METHODS In an open-label, multicenter, parallel-group trial, we randomly assigned 4146 patients with stable chest pain who had been referred to a cardiology clinic for evaluation to standard care plus CTA (2073 patients) or to standard care alone (2073 patients). Investigations, treatments, and clinical outcomes were assessed over 3 to 7 years of follow-up. The primary end point was death from coronary heart disease or nonfatal myocardial infarction at 5 years. RESULTS The median duration of follow-up was 4.8 years, which yielded 20,254 patient-years of follow-up. The 5-year rate of the primary end point was lower in the CTA group than in the standard-care group (2.3% [48 patients] vs. 3.9% [81 patients]; hazard ratio, 0.59; 95% confidence interval [CI], 0.41 to 0.84; P=0.004). Although the rates of invasive coronary angiography and coronary revascularization were higher in the CTA group than in the standard-care group in the first few months of follow-up, overall rates were similar at 5 years: invasive coronary angiography was performed in 491 patients in the CTA group and in 502 patients in the standard-care group (hazard ratio, 1.00; 95% CI, 0.88 to 1.13), and coronary revascularization was performed in 279 patients in the CTA group and in 267 in the standard-care group (hazard ratio, 1.07; 95% CI, 0.91 to 1.27). However, more preventive therapies were initiated in patients in the CTA group (odds ratio, 1.40; 95% CI, 1.19 to 1.65), as were more antianginal therapies (odds ratio, 1.27; 95% CI, 1.05 to 1.54). There were no significant between-group differences in the rates of cardiovascular or noncardiovascular deaths or deaths from any cause. CONCLUSIONS In this trial, the use of CTA in addition to standard care in patients with stable chest pain resulted in a significantly lower rate of death from coronary heart disease or nonfatal myocardial infarction at 5 years than standard care alone, without resulting in a significantly higher rate of coronary angiography or coronary revascularization. (Funded by the Scottish Government Chief Scientist Office and others; SCOT-HEART ClinicalTrials.gov number, NCT01149590 .).
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Affiliation(s)
- David E Newby
- From the University of Edinburgh, Edinburgh (D.E.N., P.D.A., N.A.B., M.R.D., A.H., S.L., N.L.M., J.N., A.S.V.S., E.J.R.B., M.C.W.), the University of Glasgow, Glasgow (C.B., G.R.), the University of East Anglia, Norwich (M.F.), NHS Fife, Kirkcaldy (S.M.), and Queen Mary University, London (A.D.T.) - all in the United Kingdom; and the University of Limerick, Limerick, Ireland (J.F.)
| | - Philip D Adamson
- From the University of Edinburgh, Edinburgh (D.E.N., P.D.A., N.A.B., M.R.D., A.H., S.L., N.L.M., J.N., A.S.V.S., E.J.R.B., M.C.W.), the University of Glasgow, Glasgow (C.B., G.R.), the University of East Anglia, Norwich (M.F.), NHS Fife, Kirkcaldy (S.M.), and Queen Mary University, London (A.D.T.) - all in the United Kingdom; and the University of Limerick, Limerick, Ireland (J.F.)
| | - Colin Berry
- From the University of Edinburgh, Edinburgh (D.E.N., P.D.A., N.A.B., M.R.D., A.H., S.L., N.L.M., J.N., A.S.V.S., E.J.R.B., M.C.W.), the University of Glasgow, Glasgow (C.B., G.R.), the University of East Anglia, Norwich (M.F.), NHS Fife, Kirkcaldy (S.M.), and Queen Mary University, London (A.D.T.) - all in the United Kingdom; and the University of Limerick, Limerick, Ireland (J.F.)
| | - Nicholas A Boon
- From the University of Edinburgh, Edinburgh (D.E.N., P.D.A., N.A.B., M.R.D., A.H., S.L., N.L.M., J.N., A.S.V.S., E.J.R.B., M.C.W.), the University of Glasgow, Glasgow (C.B., G.R.), the University of East Anglia, Norwich (M.F.), NHS Fife, Kirkcaldy (S.M.), and Queen Mary University, London (A.D.T.) - all in the United Kingdom; and the University of Limerick, Limerick, Ireland (J.F.)
| | - Marc R Dweck
- From the University of Edinburgh, Edinburgh (D.E.N., P.D.A., N.A.B., M.R.D., A.H., S.L., N.L.M., J.N., A.S.V.S., E.J.R.B., M.C.W.), the University of Glasgow, Glasgow (C.B., G.R.), the University of East Anglia, Norwich (M.F.), NHS Fife, Kirkcaldy (S.M.), and Queen Mary University, London (A.D.T.) - all in the United Kingdom; and the University of Limerick, Limerick, Ireland (J.F.)
| | - Marcus Flather
- From the University of Edinburgh, Edinburgh (D.E.N., P.D.A., N.A.B., M.R.D., A.H., S.L., N.L.M., J.N., A.S.V.S., E.J.R.B., M.C.W.), the University of Glasgow, Glasgow (C.B., G.R.), the University of East Anglia, Norwich (M.F.), NHS Fife, Kirkcaldy (S.M.), and Queen Mary University, London (A.D.T.) - all in the United Kingdom; and the University of Limerick, Limerick, Ireland (J.F.)
| | - John Forbes
- From the University of Edinburgh, Edinburgh (D.E.N., P.D.A., N.A.B., M.R.D., A.H., S.L., N.L.M., J.N., A.S.V.S., E.J.R.B., M.C.W.), the University of Glasgow, Glasgow (C.B., G.R.), the University of East Anglia, Norwich (M.F.), NHS Fife, Kirkcaldy (S.M.), and Queen Mary University, London (A.D.T.) - all in the United Kingdom; and the University of Limerick, Limerick, Ireland (J.F.)
| | - Amanda Hunter
- From the University of Edinburgh, Edinburgh (D.E.N., P.D.A., N.A.B., M.R.D., A.H., S.L., N.L.M., J.N., A.S.V.S., E.J.R.B., M.C.W.), the University of Glasgow, Glasgow (C.B., G.R.), the University of East Anglia, Norwich (M.F.), NHS Fife, Kirkcaldy (S.M.), and Queen Mary University, London (A.D.T.) - all in the United Kingdom; and the University of Limerick, Limerick, Ireland (J.F.)
| | - Stephanie Lewis
- From the University of Edinburgh, Edinburgh (D.E.N., P.D.A., N.A.B., M.R.D., A.H., S.L., N.L.M., J.N., A.S.V.S., E.J.R.B., M.C.W.), the University of Glasgow, Glasgow (C.B., G.R.), the University of East Anglia, Norwich (M.F.), NHS Fife, Kirkcaldy (S.M.), and Queen Mary University, London (A.D.T.) - all in the United Kingdom; and the University of Limerick, Limerick, Ireland (J.F.)
| | - Scott MacLean
- From the University of Edinburgh, Edinburgh (D.E.N., P.D.A., N.A.B., M.R.D., A.H., S.L., N.L.M., J.N., A.S.V.S., E.J.R.B., M.C.W.), the University of Glasgow, Glasgow (C.B., G.R.), the University of East Anglia, Norwich (M.F.), NHS Fife, Kirkcaldy (S.M.), and Queen Mary University, London (A.D.T.) - all in the United Kingdom; and the University of Limerick, Limerick, Ireland (J.F.)
| | - Nicholas L Mills
- From the University of Edinburgh, Edinburgh (D.E.N., P.D.A., N.A.B., M.R.D., A.H., S.L., N.L.M., J.N., A.S.V.S., E.J.R.B., M.C.W.), the University of Glasgow, Glasgow (C.B., G.R.), the University of East Anglia, Norwich (M.F.), NHS Fife, Kirkcaldy (S.M.), and Queen Mary University, London (A.D.T.) - all in the United Kingdom; and the University of Limerick, Limerick, Ireland (J.F.)
| | - John Norrie
- From the University of Edinburgh, Edinburgh (D.E.N., P.D.A., N.A.B., M.R.D., A.H., S.L., N.L.M., J.N., A.S.V.S., E.J.R.B., M.C.W.), the University of Glasgow, Glasgow (C.B., G.R.), the University of East Anglia, Norwich (M.F.), NHS Fife, Kirkcaldy (S.M.), and Queen Mary University, London (A.D.T.) - all in the United Kingdom; and the University of Limerick, Limerick, Ireland (J.F.)
| | - Giles Roditi
- From the University of Edinburgh, Edinburgh (D.E.N., P.D.A., N.A.B., M.R.D., A.H., S.L., N.L.M., J.N., A.S.V.S., E.J.R.B., M.C.W.), the University of Glasgow, Glasgow (C.B., G.R.), the University of East Anglia, Norwich (M.F.), NHS Fife, Kirkcaldy (S.M.), and Queen Mary University, London (A.D.T.) - all in the United Kingdom; and the University of Limerick, Limerick, Ireland (J.F.)
| | - Anoop S V Shah
- From the University of Edinburgh, Edinburgh (D.E.N., P.D.A., N.A.B., M.R.D., A.H., S.L., N.L.M., J.N., A.S.V.S., E.J.R.B., M.C.W.), the University of Glasgow, Glasgow (C.B., G.R.), the University of East Anglia, Norwich (M.F.), NHS Fife, Kirkcaldy (S.M.), and Queen Mary University, London (A.D.T.) - all in the United Kingdom; and the University of Limerick, Limerick, Ireland (J.F.)
| | - Adam D Timmis
- From the University of Edinburgh, Edinburgh (D.E.N., P.D.A., N.A.B., M.R.D., A.H., S.L., N.L.M., J.N., A.S.V.S., E.J.R.B., M.C.W.), the University of Glasgow, Glasgow (C.B., G.R.), the University of East Anglia, Norwich (M.F.), NHS Fife, Kirkcaldy (S.M.), and Queen Mary University, London (A.D.T.) - all in the United Kingdom; and the University of Limerick, Limerick, Ireland (J.F.)
| | - Edwin J R van Beek
- From the University of Edinburgh, Edinburgh (D.E.N., P.D.A., N.A.B., M.R.D., A.H., S.L., N.L.M., J.N., A.S.V.S., E.J.R.B., M.C.W.), the University of Glasgow, Glasgow (C.B., G.R.), the University of East Anglia, Norwich (M.F.), NHS Fife, Kirkcaldy (S.M.), and Queen Mary University, London (A.D.T.) - all in the United Kingdom; and the University of Limerick, Limerick, Ireland (J.F.)
| | - Michelle C Williams
- From the University of Edinburgh, Edinburgh (D.E.N., P.D.A., N.A.B., M.R.D., A.H., S.L., N.L.M., J.N., A.S.V.S., E.J.R.B., M.C.W.), the University of Glasgow, Glasgow (C.B., G.R.), the University of East Anglia, Norwich (M.F.), NHS Fife, Kirkcaldy (S.M.), and Queen Mary University, London (A.D.T.) - all in the United Kingdom; and the University of Limerick, Limerick, Ireland (J.F.)
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Otto CM. Heartbeat: Computed tomographic coronary angiography in patients with possible angina. BRITISH HEART JOURNAL 2018; 104:183-185. [DOI: 10.1136/heartjnl-2017-312851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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