1
|
Choustoulakis E, Cosyns B, Sonck J, Roosens B, Pien K, Argacha JF, Lochy S, Hubloue I, de Mey J, Putman K. FFRct use for acute chest pain triage in the emergency department: a cost-effectiveness analysis. Acta Cardiol 2024; 79:167-178. [PMID: 38051089 DOI: 10.1080/00015385.2023.2285552] [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: 10/16/2022] [Accepted: 11/14/2023] [Indexed: 12/07/2023]
Abstract
AIMS To model and assess the cost-effectiveness of CT-based fractional flow reserve (FFRct) for a population of low to intermediate risk patients for coronary artery disease (CAD) presenting to the emergency department (ED) with acute chest pain. METHODS AND RESULTS Using a decision tree model with a 1 year time horizon and from a health care perspective, two diagnostic pathways using FFRct are compared to current clinical routine combining coronary computed tomography angiography (CCTA) with an exercise test. Model data are drawn from the literature and nationally reported data. Outcomes are assessed as the number of avoided invasive coronary angiographies (ICAs) showing no obstructive CAD and quality of life (QoL) in a theoretical cohort of 1000 patients. Sensitivity analyses are performed to test the robustness of the results. Determining FFRct when CCTA is inconclusive is a cost-effective and dominant strategy with a potential saving of 198€/patient, 154 avoided unnecessary ICA showing no obstructive CAD (uICA)/1000 patients and an average improvement in QoL of 0.008 QALY/patient. With an additional 574€/patient, 8 avoided uICA/1000 patients and an improvement in QoL of 0.001 QALY/patient, a strategy where FFRct is always performed is cost-effective only when considering high cost-effectiveness thresholds. CONCLUSIONS For patients presenting to the ED with acute chest pain and a low to intermediate pre-test probability of CAD, a diagnostic strategy where FFRct is determined after an inconclusive CCTA is cost-effective. Clinical trials investigating both sensitivity and specificity of FFRct, as well as QoL associated with the use of this technology in this setting are warranted.
Collapse
Affiliation(s)
- Eleftherios Choustoulakis
- Department of Cardiology, Universitair Ziekenhuis Brussel, Brussels, Belgium
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Bernard Cosyns
- Department of Cardiology, Centrum voor Hart- en Vaatziekten, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Jeroen Sonck
- Cardiovascular Center Aalst, OLV Clinic, Aalst, Belgium
- Department of Advanced Biomedical Sciences, University of Naples, Federico II, Naples, Italy
| | - Bram Roosens
- Department of Cardiology, Centrum voor Hart- en Vaatziekten, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Karen Pien
- Department of Medical Registration, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Jean-François Argacha
- Department of Cardiology, Centrum voor Hart- en Vaatziekten, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Stijn Lochy
- Department of Cardiology, Centrum voor Hart- en Vaatziekten, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Ives Hubloue
- Department of Emergency Medicine, Emergency and Disaster Medicine, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Johan de Mey
- Department of Radiology, Universitair Ziekenhuis Brussel, Brussels, Belgium
| | - Koen Putman
- Department of Public Health, Faculty of Medicine and Pharmacy, Interuniversity Centre of Health Economic Research, Vrije Universiteit Brussel, Brussels, Belgium
| |
Collapse
|
2
|
Cury RC, Leipsic J, Abbara S, Achenbach S, Berman D, Bittencourt M, Budoff M, Chinnaiyan K, Choi AD, Ghoshhajra B, Jacobs J, Koweek L, Lesser J, Maroules C, Rubin GD, Rybicki FJ, Shaw LJ, Williams MC, Williamson E, White CS, Villines TC, Blankstein R. CAD-RADS™ 2.0 - 2022 Coronary Artery Disease-Reporting and Data System: An Expert Consensus Document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Cardiology (ACC), the American College of Radiology (ACR), and the North America Society of Cardiovascular Imaging (NASCI). JACC Cardiovasc Imaging 2022; 15:1974-2001. [PMID: 36115815 DOI: 10.1016/j.jcmg.2022.07.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 03/10/2022] [Accepted: 07/02/2022] [Indexed: 12/14/2022]
Abstract
Coronary Artery Disease Reporting and Data System (CAD-RADS) was created to standardize reporting system for patients undergoing coronary CT angiography (CCTA) and to guide possible next steps in patient management. The goal of this updated 2022 CAD-RADS 2.0 is to improve the initial reporting system for CCTA by considering new technical developments in cardiac CT, including data from recent clinical trials and new clinical guidelines. The updated CAD-RADS classification will follow an established framework of stenosis, plaque burden, and modifiers, which will include assessment of lesion-specific ischemia using CT fractional-flow-reserve (CT-FFR) or myocardial CT perfusion (CTP), when performed. Similar to the method used in the original CAD-RADS version, the determinant for stenosis severity classification will be the most severe coronary artery luminal stenosis on a per-patient basis, ranging from CAD-RADS 0 (zero) for absence of any plaque or stenosis to CAD-RADS 5 indicating the presence of at least one totally occluded coronary artery. Given the increasing data supporting the prognostic relevance of coronary plaque burden, this document will provide various methods to estimate and report total plaque burden. The addition of P1 to P4 descriptors are used to denote increasing categories of plaque burden. The main goal of CAD-RADS, which should always be interpreted together with the impression found in the report, remains to facilitate communication of test results with referring physicians along with suggestions for subsequent patient management. In addition, CAD-RADS will continue to provide a framework of standardization that may benefit education, research, peer-review, artificial intelligence development, clinical trial design, population health and quality assurance with the ultimate goal of improving patient care.
Collapse
Affiliation(s)
- Ricardo C Cury
- Miami Cardiac and Vascular Institute and Baptist Health of South Florida, Miami, Florida, USA.
| | - Jonathon Leipsic
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada
| | - Suhny Abbara
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Stephan Achenbach
- Friedrich-Alexander-Universität, Department of Cardiology, Erlangen, Germany
| | - Daniel Berman
- Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Marcio Bittencourt
- Division of Cardiology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Matthew Budoff
- David Geffen School of Medicine, UCLA, Los Angeles, California, USA
| | | | - Andrew D Choi
- The George Washington University School of Medicine, Washington, DC, USA
| | - Brian Ghoshhajra
- Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jill Jacobs
- NYU Langone Medical Center, New York, New York, USA
| | - Lynne Koweek
- Department of Radiology, Duke University, Durham, North Carolina, USA
| | - John Lesser
- Division of Cardiology, Minneapolis Heart Institute, Minneapolis, Minnesota, USA
| | | | - Geoffrey D Rubin
- Department of Medical Imaging, University of Arizona, Tucson, Arizona, USA
| | - Frank J Rybicki
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Leslee J Shaw
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Eric Williamson
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Todd C Villines
- Division of Cardiology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Ron Blankstein
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| |
Collapse
|
3
|
Cury RC, Leipsic J, Abbara S, Achenbach S, Berman D, Bittencourt M, Budoff M, Chinnaiyan K, Choi AD, Ghoshhajra B, Jacobs J, Koweek L, Lesser J, Maroules C, Rubin GD, Rybicki FJ, Shaw LJ, Williams MC, Williamson E, White CS, Villines TC, Blankstein R. CAD-RADS™ 2.0 - 2022 Coronary Artery Disease - Reporting and Data System.: An expert consensus document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Cardiology (ACC), the American College of Radiology (ACR) and the North America Society of Cardiovascular Imaging (NASCI). J Am Coll Radiol 2022; 19:1185-1212. [PMID: 36436841 DOI: 10.1016/j.jacr.2022.09.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Coronary Artery Disease Reporting and Data System (CAD-RADS) was created to standardize reporting system for patients undergoing coronary CT angiography (CCTA) and to guide possible next steps in patient management. The goal of this updated 2022 CAD-RADS 2.0 is to improve the initial reporting system for CCTA by considering new technical developments in Cardiac CT, including data from recent clinical trials and new clinical guidelines. The updated CAD-RADS classification will follow an established framework of stenosis, plaque burden, and modifiers, which will include assessment of lesion-specific ischemia using CT fractional-flow-reserve (CT-FFR) or myocardial CT perfusion (CTP), when performed. Similar to the method used in the original CAD-RADS version, the determinant for stenosis severity classification will be the most severe coronary artery luminal stenosis on a per-patient basis, ranging from CAD-RADS 0 (zero) for absence of any plaque or stenosis to CAD-RADS 5 indicating the presence of at least one totally occluded coronary artery. Given the increasing data supporting the prognostic relevance of coronary plaque burden, this document will provide various methods to estimate and report total plaque burden. The addition of P1 to P4 descriptors are used to denote increasing categories of plaque burden. The main goal of CAD-RADS, which should always be interpreted together with the impression found in the report, remains to facilitate communication of test results with referring physicians along with suggestions for subsequent patient management. In addition, CAD-RADS will continue to provide a framework of standardization that may benefit education, research, peer-review, artificial intelligence development, clinical trial design, population health and quality assurance with the ultimate goal of improving patient care.
Collapse
Affiliation(s)
- Ricardo C Cury
- Miami Cardiac and Vascular Institute and Baptist Health of South Florida, 8900 N Kendall Drive, Miami FL, 33176, USA.
| | - Jonathon Leipsic
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada
| | - Suhny Abbara
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Stephan Achenbach
- Friedrich-Alexander-Universität, Department of Cardiology, Erlangen, Germany
| | | | | | - Matthew Budoff
- David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | | | - Andrew D Choi
- The George Washington University School of Medicine, Washington, DC, USA
| | - Brian Ghoshhajra
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Jill Jacobs
- NYU Langone Medical Center, New York, NY, USA
| | - Lynne Koweek
- Department of Radiology, Duke University, Durham, NC, USA
| | - John Lesser
- Division of Cardiology, Minneapolis Heart Institute, Minneapolis, MN, USA
| | | | - Geoffrey D Rubin
- Department of Medical Imaging, University of Arizona, Tucson, AZ, USA
| | - Frank J Rybicki
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Leslee J Shaw
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | - Todd C Villines
- Division of Cardiology, University of Virginia Health System, Charlottesville, VA, USA
| | - Ron Blankstein
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
4
|
Cury RC, Leipsic J, Abbara S, Achenbach S, Berman D, Bittencourt M, Budoff M, Chinnaiyan K, Choi AD, Ghoshhajra B, Jacobs J, Koweek L, Lesser J, Maroules C, Rubin GD, Rybicki FJ, Shaw LJ, Williams MC, Williamson E, White CS, Villines TC, Blankstein R. CAD-RADS™ 2.0 - 2022 Coronary Artery Disease-Reporting and Data System: An Expert Consensus Document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Cardiology (ACC), the American College of Radiology (ACR), and the North America Society of Cardiovascular Imaging (NASCI). J Cardiovasc Comput Tomogr 2022; 16:536-557. [PMID: 35864070 DOI: 10.1016/j.jcct.2022.07.002] [Citation(s) in RCA: 74] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 03/10/2022] [Accepted: 07/02/2022] [Indexed: 12/14/2022]
Abstract
Coronary Artery Disease Reporting and Data System (CAD-RADS) was created to standardize reporting system for patients undergoing coronary CT angiography (CCTA) and to guide possible next steps in patient management. The goal of this updated 2022 CAD-RADS 2.0 is to improve the initial reporting system for CCTA by considering new technical developments in Cardiac CT, including data from recent clinical trials and new clinical guidelines. The updated CAD-RADS classification will follow an established framework of stenosis, plaque burden, and modifiers, which will include assessment of lesion-specific ischemia using CT fractional-flow-reserve (CT-FFR) or myocardial CT perfusion (CTP), when performed. Similar to the method used in the original CAD-RADS version, the determinant for stenosis severity classification will be the most severe coronary artery luminal stenosis on a per-patient basis, ranging from CAD-RADS 0 (zero) for absence of any plaque or stenosis to CAD-RADS 5 indicating the presence of at least one totally occluded coronary artery. Given the increasing data supporting the prognostic relevance of coronary plaque burden, this document will provide various methods to estimate and report total plaque burden. The addition of P1 to P4 descriptors are used to denote increasing categories of plaque burden. The main goal of CAD-RADS, which should always be interpreted together with the impression found in the report, remains to facilitate communication of test results with referring physicians along with suggestions for subsequent patient management. In addition, CAD-RADS will continue to provide a framework of standardization that may benefit education, research, peer-review, artificial intelligence development, clinical trial design, population health and quality assurance with the ultimate goal of improving patient care.
Collapse
Affiliation(s)
- Ricardo C Cury
- Miami Cardiac and Vascular Institute and Baptist Health of South Florida, Miami FL, USA.
| | - Jonathon Leipsic
- Department of Radiology, University of British Columbia, Vancouver, BC, Canada
| | - Suhny Abbara
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX, USA
| | - Stephan Achenbach
- Friedrich-Alexander-Universität, Department of Cardiology, Erlangen, Germany
| | | | | | - Matthew Budoff
- David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | | | - Andrew D Choi
- The George Washington University School of Medicine, Washington, DC, USA
| | - Brian Ghoshhajra
- Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Jill Jacobs
- NYU Langone Medical Center, New York, NY, USA
| | - Lynne Koweek
- Department of Radiology, Duke University, Durham, NC, USA
| | - John Lesser
- Division of Cardiology, Minneapolis Heart Institute, Minneapolis, MN, USA
| | | | - Geoffrey D Rubin
- Department of Medical Imaging, University of Arizona, Tucson, AZ, USA
| | - Frank J Rybicki
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Leslee J Shaw
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | - Todd C Villines
- Division of Cardiology, University of Virginia Health System, Charlottesville, VA, USA
| | - Ron Blankstein
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
| |
Collapse
|
5
|
Cury RC, Leipsic J, Abbara S, Achenbach S, Berman D, Bittencourt M, Budoff M, Chinnaiyan K, Choi AD, Ghoshhajra B, Jacobs J, Koweek L, Lesser J, Maroules C, Rubin GD, Rybicki FJ, Shaw LJ, Williams MC, Williamson E, White CS, Villines TC, Blankstein R. CAD-RADS™ 2.0 - 2022 Coronary Artery Disease - Reporting and Data System An Expert Consensus Document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Cardiology (ACC), the American College of Radiology (ACR) and the North America Society of Cardiovascular Imaging (NASCI). Radiol Cardiothorac Imaging 2022; 4:e220183. [PMID: 36339062 PMCID: PMC9627235 DOI: 10.1148/ryct.220183] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 03/10/2022] [Accepted: 07/02/2022] [Indexed: 06/16/2023]
Abstract
Coronary Artery Disease Reporting and Data System (CAD-RADS) was created to standardize reporting system for patients undergoing coronary CT angiography (CCTA) and to guide possible next steps in patient management. The goal of this updated 2022 CAD-RADS 2.0 is to improve the initial reporting system for CCTA by considering new technical developments in Cardiac CT, including data from recent clinical trials and new clinical guidelines. The updated CAD-RADS classification will follow an established framework of stenosis, plaque burden, and modifiers, which will include assessment of lesion-specific ischemia using CT fractional-flow-reserve (CT-FFR) or myocardial CT perfusion (CTP), when performed. Similar to the method used in the original CAD-RADS version, the determinant for stenosis severity classification will be the most severe coronary artery luminal stenosis on a per-patient basis, ranging from CAD-RADS 0 (zero) for absence of any plaque or stenosis to CAD-RADS 5 indicating the presence of at least one totally occluded coronary artery. Given the increasing data supporting the prognostic relevance of coronary plaque burden, this document will provide various methods to estimate and report total plaque burden. The addition of P1 to P4 descriptors are used to denote increasing categories of plaque burden. The main goal of CAD-RADS, which should always be interpreted together with the impression found in the report, remains to facilitate communication of test results with referring physicians along with suggestions for subsequent patient management. In addition, CAD-RADS will continue to provide a framework of standardization that may benefit education, research, peer-review, artificial intelligence development, clinical trial design, population health and quality assurance with the ultimate goal of improving patient care. Keywords: Coronary Artery Disease, Coronary CTA, CAD-RADS, Reporting and Data System, Stenosis Severity, Report Standardization Terminology, Plaque Burden, Ischemia Supplemental material is available for this article. This article is published synchronously in Radiology: Cardiothoracic Imaging, Journal of Cardiovascular Computed Tomography, JACC: Cardiovascular Imaging, Journal of the American College of Radiology, and International Journal for Cardiovascular Imaging. © 2022 Society of Cardiovascular Computed Tomography. Published by RSNA with permission.
Collapse
Affiliation(s)
- Ricardo C. Cury
- Miami Cardiac and Vascular Institute and Baptist Health of South
Florida, 8900 N Kendall Drive, Miami FL, 33176, USA
| | | | - Suhny Abbara
- Department of Radiology, UT Southwestern Medical Center, Dallas, TX,
USA
| | - Stephan Achenbach
- Friedrich-Alexander-Universität, Department of Cardiology,
Ulmenweg 18, 90154, Erlangen, Germany
| | | | | | | | | | - Andrew D. Choi
- The George Washington University School of Medicine, USA
| | | | - Jill Jacobs
- NYU Langone Medical Center, 550 First Avenue, New York, NY, 10016,
USA
| | | | - John Lesser
- Division of Cardiology, Minneapolis Heart Institute, USA
| | | | | | - Frank J. Rybicki
- Department of Radiology, University of Cincinnati College of
Medicine, USA
| | | | | | | | | | - Todd C. Villines
- Division of Cardiology, University of Virginia Health System,
USA
| | - Ron Blankstein
- Brigham and Women's Hospital, Harvard Medical School,
USA
| |
Collapse
|
6
|
Mehta P, McDonald S, Hirani R, Good D, Diercks D. Major adverse cardiac events after emergency department evaluation of chest pain patients with advanced testing: Systematic review and meta-analysis. Acad Emerg Med 2022; 29:748-764. [PMID: 34741781 DOI: 10.1111/acem.14407] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 10/15/2021] [Accepted: 10/26/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Our primary objective was to describe the risk of major adverse cardiac events (MACE) at 1, 6, and 12 months after a negative coronary computed tomography angiogram (cCTA), electrocardiogram (ECG) stress test, stress echocardiography, and myocardial perfusion scintigraphy (MPS) in low- to intermediate-risk patients. METHODS Initially, 952 articles were identified for screening, 81 met criteria for full-text review, and once risk of bias was assessed, 33 articles were included in this meta-analysis. We utilized a random-effects model to assess pooled MACE event proportion for patients undergoing evaluation of acute coronary syndrome (ACS) when risk stratified to a low- to intermediate-risk category after undergoing standard testing. Heterogeneity analysis was performed using Cochrane's Q-test and I2 statistic. RESULTS Twenty-one studies evaluated follow-up at 1 month with cCTA having a 0.09% (95% confidence interval [CI] = 0.03% to 0.26%) pooled MACE compared to 0.23% (95% CI = 0.01% to 5.8%) of the exercise stress testing (p = 1). MPS and cCTA had an overall event rate of 0.15% (95% CI = 0.06% to 0.41%) at 6 months (I2 = 0%). At 12 months, a subgroup analysis found a pooled cCTA MACE of 0.16% (95% CI = 0.04% to 0.65%) compared to 1.68% (95% CI = 0.01% to 2.6%) for stress echocardiography with low within-group heterogeneity (I2 = 0%). Subgroup analysis of cCTA with no disease versus nonobstructive disease (<50% stenosis) did not find statistical difference in the MACE at both 1 month (0.17% [95% CI = 0.04% to 0.67%] vs. 0.06% [95% CI = 0.01% to 0.34%]) and 12 months (0.44% [95% CI = 0.09% to 2.2% vs. 0.54% [95% CI = 0.19% to 1.5%]). CONCLUSIONS Patients presenting with chest pain who have a coronary CTA showing < 50% stenosis, negative ECG stress test, stress echocardiography, or stress myocardial perfusion scan in the past 12 months can be discharged without any further risk stratification if their ECG and troponin are reassuring given low MACE.
Collapse
Affiliation(s)
- Prayag Mehta
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Samuel McDonald
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA.,Clinical Informatics Center, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Raiz Hirani
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Daniel Good
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Deborah Diercks
- Department of Emergency Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| |
Collapse
|
7
|
Yoshihara S. Acute coronary syndrome on non-electrocardiogram-gated contrast-enhanced computed tomography. World J Radiol 2022; 14:30-46. [PMID: 35317242 PMCID: PMC8891644 DOI: 10.4329/wjr.v14.i2.30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 12/14/2021] [Accepted: 02/16/2022] [Indexed: 02/06/2023] Open
Abstract
It is not rare for acute coronary syndrome (ACS) patients to present with symptoms that are atypical, rather than chest pain. It is sometimes difficult to achieve a definitive diagnosis of ACS for such patients who present with atypical symptoms, normal initial biomarkers of myocardial necrosis, and normal or nondiagnostic electrocardiograms (ECGs). Although cardiac CT allows for assessments of coronary artery stenosis as well as myocardial perfusion defect in patients with suspected ACS, it requires ECG gating and is usually performed with high-performance multislice CT for highly probable ACS patients. However, several recent reports have stated that ACS is detectable by myocardial perfusion defects even on routine non-ECG-gated contrast-enhanced CT. A growing number of contrast-enhanced CT scans are now being performed in emergency departments in search of pathologies responsible for a patient’s presenting symptoms. In order to avoid inappropriate management for this life-threatening event, clinicians should be aware that myocardial perfusion defect is more commonly detectable even on routine non-ECG-gated contrast-enhanced CT performed in search of other pathologies.
Collapse
Affiliation(s)
- Shu Yoshihara
- Department of Diagnostic Radiology, Iwata City Hospital, Iwata 438-8550, Japan
| |
Collapse
|
8
|
Mansour HH, Alajerami YS, Abushab KM, Quffa KM. The diagnostic accuracy of coronary computed tomography angiography in patients with and without previous coronary interventions. J Med Imaging Radiat Sci 2022; 53:81-86. [PMID: 34987013 DOI: 10.1016/j.jmir.2021.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 09/28/2021] [Accepted: 10/18/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Invasive coronary angiography (ICA) is the gold standard for imaging coronary arteries and the severity of coronary artery disease (CAD). Coronary computed tomography angiography (CCTA) has undergone remarkable progress in the diagnosis of CAD. OBJECTIVES To evaluate the effect of prior vs no previous coronary interventions on the diagnostic accuracy of CCTA as an alternative to ICA to improve health outcomes for patients with suspected CAD. METHODS A prospective cohort study was carried out among patients suspected of CAD and for evaluation of grafts and stents to investigate recurrent ischemic symptoms. 120 patients imaged by CCTA were then referred to ICA, which is considered the gold standard. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of CCTA were assessed relative to ICA. RESULTS Based on a per-patient analysis, the comparison with ICA reveals variations in sensitivity, specificity, PPV, NPV and accuracy of CCTA. In patients without any previous coronary interventions, the sensitivity was 97.8%, and specificity was 95.6%. The PPV and NPV were 97.8% and 95.5%, respectively. Regarding patients with coronary artery bypass grafts (CABG), the sensitivity was 95% and specificity 100%. The PPV and NPV were 100% and 90.9%, respectively. Regarding patients with prior percutaneous coronary intervention (PCI), the results were a sensitivity of 84.6%, specificity of 77.8%, PPV of 84.6% and NPV of 77.8%. CONCLUSION CCTA is a powerful diagnostic tool, especially for the evaluation of the major coronary arteries and evaluation of patients with prior CABG. ICA is recommended for evaluation of patients with an intracoronary stent.
Collapse
Affiliation(s)
- Husam H Mansour
- Radiology Department, Al-Shifa Hospital, Gaza-Palestine, Palestine; Medical Imaging Department, Al-Azhar University, Gaza-Palestine, Palestine.
| | - Yasser S Alajerami
- Medical Imaging Department, Al-Azhar University, Gaza-Palestine, Palestine
| | - Khaled M Abushab
- Medical Imaging Department, Al-Azhar University, Gaza-Palestine, Palestine
| | - Khetam M Quffa
- Medical Imaging Department, Al-Azhar University, Gaza-Palestine, Palestine
| |
Collapse
|
9
|
Grandhi GR, Mszar R, Cainzos-Achirica M, Rajan T, Latif MA, Bittencourt MS, Shaw LJ, Batlle JC, Blankstein R, Blaha MJ, Cury RC, Nasir K. Coronary Calcium to Rule Out Obstructive Coronary Artery Disease in Patients With Acute Chest Pain. JACC Cardiovasc Imaging 2021; 15:271-280. [PMID: 34656462 DOI: 10.1016/j.jcmg.2021.06.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 06/17/2021] [Accepted: 06/24/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVES This study aimed to evaluate the ability of coronary artery calcium (CAC) as an initial diagnostic tool to rule out obstructive coronary artery disease (CAD) in a very large registry of patients presenting to the emergency department (ED) with acute chest pain (CP) who were at low to intermediate risk for acute coronary syndrome (ACS). BACKGROUND It is not yet well established whether CAC can be used to rule out obstructive CAD in the ED setting. METHODS We included patients from the Baptist Health South Florida Chest Pain Registry presenting to the ED with CP at low to intermediate risk for ACS (Thrombolysis In Myocardial Infarction risk score ≤2, normal/nondiagnostic electrocardiography, and troponin levels) who underwent CAC and coronary computed tomography angiography (CCTA) procedures for evaluation of ACS. To assess the diagnostic accuracy of CAC testing to diagnose obstructive CAD and identify the need for coronary revascularization during hospitalization, we estimated sensitivity, specificity, positive predictive values (PPV), and negative predictive values (NPV). RESULTS Our study included 5,192 patients (mean age: 53.5 ± 10.8 years; 46% male; 62% Hispanic). Overall, 2,902 patients (56%) had CAC = 0, of which 135 (4.6%) had CAD (114 [3.9%] nonobstructive and 21 [0.7%] obstructive). Among those with CAC >0, 23% had obstructive CAD. Sensitivity, specificity, PPV, and NPV of CAC testing to diagnose obstructive CAD were 96.2%, 62.4%, 22.4%, and 99.3%, respectively. The NPV for identifying those who needed revascularization was 99.6%. Among patients with CAC = 0, 11 patients (0.4%) underwent revascularization, and the number needed to test with CCTA to detect 1 patient who required revascularization was 264. CONCLUSIONS In a large population presenting to ED with CP at low to intermediate risk, CAC = 0 was common. CAC = 0 ruled out obstructive CAD and revascularization in more than 99% of the patients, and <5% with CAC = 0 had any CAD. Integrating CAC testing very early in CP evaluation may be effective in appropriate triage of patients by identifying individuals who can safely defer additional testing and more invasive procedures.
Collapse
Affiliation(s)
- Gowtham R Grandhi
- Miami Cardiac and Vascular Institute, Baptist Health of South Florida, Miami, Florida, USA; Department of Medicine, MedStar Union Memorial Hospital, Baltimore, Maryland, USA
| | - Reed Mszar
- Center for Outcomes Research and Evaluation, Yale New Haven Health, New Haven, Connecticut, USA
| | - Miguel Cainzos-Achirica
- Division of Health Equity and Disparities Research, Center for Outcomes Research, The Houston Methodist Research Institute, Houston, Texas, USA; Department of Cardiovascular Medicine, Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA
| | - Tanuja Rajan
- The Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Baltimore, Maryland, USA
| | - Muhammad A Latif
- Russell H. Morgan Department of Radiology and Radiological Science, Division of Interventional Radiology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Marcio S Bittencourt
- Center for Clinical and Epidemiological Research, University Hospital, University of São Paulo, São Paulo, Brazil; Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Leslee J Shaw
- Weill Cornell Medical College, New York, New York, USA
| | - Juan C Batlle
- Miami Cardiac and Vascular Institute, Baptist Health of South Florida, Miami, Florida, USA; Department of Radiology, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
| | - Ron Blankstein
- Cardiovascular Division and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michael J Blaha
- The Johns Hopkins Ciccarone Center for Prevention of Cardiovascular Disease, Baltimore, Maryland, USA
| | - Ricardo C Cury
- Miami Cardiac and Vascular Institute, Baptist Health of South Florida, Miami, Florida, USA; Department of Radiology, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
| | - Khurram Nasir
- Division of Health Equity and Disparities Research, Center for Outcomes Research, The Houston Methodist Research Institute, Houston, Texas, USA; Department of Cardiovascular Medicine, Division of Cardiovascular Prevention and Wellness, Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA; Department of Cardiovascular Medicine, Center for Cardiovascular Computational and Precision Health (C3-PH), Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas, USA.
| |
Collapse
|
10
|
Grandhi GR, Batlle JC, Maroules CD, Janowitz W, Peña CS, Ziffer JA, Macedo R, Nasir K, Cury RC. Combined stress myocardial CT perfusion and coronary CT angiography as a feasible strategy among patients presenting with acute chest pain to the emergency department. J Cardiovasc Comput Tomogr 2020; 15:129-136. [PMID: 32807703 DOI: 10.1016/j.jcct.2020.06.195] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 05/30/2020] [Accepted: 06/13/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND A combined approach of myocardial CT perfusion (CTP) with coronary CT angiography (CTA) was shown to have better diagnostic accuracy than coronary CTA alone. However, data on cost benefits and length of stay when compared to other perfusion imaging modalities has not been evaluated. Therefore, we aim to perform a feasibility study to assess direct costs and length of stay of a combined stress CTP/CTA and use SPECT myocardial perfusion imaging (SPECT-MPI) as a benchmark, among chest pain patients at intermediate-risk for acute coronary syndrome (ACS) presenting to the emergency department (ED). METHODS This is a prospective two-arm clinical trial (NCT02538861) with 43 patients enrolled in stress CTP/CTA arm (General Electric Revolution CT) and 102 in SPECT-MPI arm. Mean age of the study population was 65 ± 12 years; 56% were men. We used multivariable linear regression analysis to compare length of stay and direct costs between the two modalities. RESULTS Overall, 9 out of the 43 patients (21%) with CTP/CTA testing had an abnormal test. Of these 9 patients, 7 patients underwent invasive coronary angiography and 6 patients were found to have obstructive coronary artery disease. Normal CTP/CTA test was found in 34 patients (79%), who were discharged home and all patients were free of major adverse cardiac events at 30 days. The mean length of stay was significantly shorter by 28% (mean difference: 14.7 h; 95% CI: 0.7, 21) among stress CTP/CTA (20 h [IQR: 16, 37]) compared to SPECT-MPI (30 h [IQR: 19, 44.5]). Mean direct costs were significantly lower by 44% (mean difference: $1535; 95% CI: 987, 2082) among stress CTA/CTP ($1750 [IQR: 1474, 2114] compared to SPECT-MPI ($2837 [IQR: 2491, 3554]). CONCLUSION Combined stress CTP/CTA is a feasible strategy for evaluation of chest pain patients presenting to ED at intermediate-risk for ACS and has the potential to lead to shorter length of stay and lower direct costs.
Collapse
Affiliation(s)
- Gowtham R Grandhi
- Miami Cardiac & Vascular Institute, Baptist Health South Florida, Miami, FL, USA; Department of Medicine, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - Juan C Batlle
- Miami Cardiac & Vascular Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | | | - Warren Janowitz
- Miami Cardiac & Vascular Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Constantino S Peña
- Miami Cardiac & Vascular Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Jack A Ziffer
- Miami Cardiac & Vascular Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Robson Macedo
- Miami Cardiac & Vascular Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA
| | - Khurram Nasir
- Division of Cardiovascular Prevention & Wellness, Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist, Houston, TX, USA; Center for Outcomes Research, Houston Methodist, Houston, TX, USA
| | - Ricardo C Cury
- Miami Cardiac & Vascular Institute, Baptist Health South Florida, Miami, FL, USA; Department of Radiology, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, USA.
| |
Collapse
|
11
|
Impact of Education-based HEART Score Pathway on Coronary Computed Tomography Angiography Utilization and Yield in the Emergency Department. Crit Pathw Cardiol 2020; 19:200-205. [PMID: 32701592 DOI: 10.1097/hpc.0000000000000234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE There is a growing consensus to reduce unnecessary testing among low-risk chest pain patients. The objective of this study was to evaluate the impact of implementing an education-based HEART score pathway in the emergency department on coronary computed tomography angiography (CCTA) utilization and yield. METHODS A retrospective before and after intervention study was conducted at a single site. Adult emergency department patients undergoing CCTA for suspected acute coronary syndrome were included. Primary outcomes were CCTA utilization and yield. Utilization was defined as the percentage of patients evaluated with CCTA and yield was calculated as the percentage of patients with a diagnosis of obstructive coronary artery disease, defined as ≥50% stenosis in any one coronary artery due to atherosclerosis. RESULTS 1540 patients undergoing CCTAs were included. CCTA utilization before and after were 2.2% [95% confidence interval (CI) 2.0-2.3] and 2.0% (95% CI 1.9-2.2), respectively; mean difference 0.1% (95% CI -0.1 to 0.3; P = 0.21). The mean age was 53 years (SD = 11) and females were 52%. Of 1477 patients included in CCTA yield analysis, patients diagnosed with obstructive coronary artery disease before and after were 15.0% (95% CI 12.6-17.7) and 16.2% (95% CI 13.6-19.1), respectively; mean difference 1.2% (95% CI -2.6 to 5.1; P = 0.53). CONCLUSIONS There was no significant change in the CCTA utilization or yield after the implementation of an education-based HEART pathway in a large academic center. Our findings suggest adopting a more comprehensive approach for deploying such evidence-based protocols to increase institutional compliance.
Collapse
|
12
|
Batlle JC, Kirsch J, Bolen MA, Bandettini WP, Brown RKJ, Francois CJ, Galizia MS, Hanneman K, Inacio JR, Johnson TV, Khosa F, Krishnamurthy R, Rajiah P, Singh SP, Tomaszewski CA, Villines TC, Wann S, Young PM, Zimmerman SL, Abbara S. ACR Appropriateness Criteria® Chest Pain-Possible Acute Coronary Syndrome. J Am Coll Radiol 2020; 17:S55-S69. [PMID: 32370978 DOI: 10.1016/j.jacr.2020.01.027] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 01/25/2020] [Indexed: 12/17/2022]
Abstract
Chest pain is a frequent cause for emergency department visits and inpatient evaluation, with particular concern for acute coronary syndrome as an etiology, since cardiovascular disease is the leading cause of death in the United States. Although history-based, electrocardiographic, and laboratory evaluations have shown promise in identifying coronary artery disease, early accurate diagnosis is paramount and there is an important role for imaging examinations to determine the presence and extent of anatomic coronary abnormality and ischemic physiology, to guide management with regard to optimal medical therapy or revascularization, and ultimately to thereby improve patient outcomes. A summary of the various methods for initial imaging evaluation of suspected acute coronary syndrome is outlined in this document. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
Collapse
Affiliation(s)
- Juan C Batlle
- Miami Cardiac and Vascular Institute and Baptist Health of South Florida, Miami, Florida.
| | - Jacobo Kirsch
- Panel Chair, Cleveland Clinic Florida, Weston, Florida
| | | | - W Patricia Bandettini
- National Institutes of Health, Bethesda, Maryland; Society for Cardiovascular Magnetic Resonance
| | | | | | | | - Kate Hanneman
- Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Joao R Inacio
- The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Thomas V Johnson
- Sanger Heart and Vascular Institute, Charlotte, North Carolina; Cardiology Expert
| | - Faisal Khosa
- Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | | | | | | | - Todd C Villines
- University of Virginia Health Center, Charlottesville, Virginia; Society of Cardiovascular Computed Tomography
| | - Samuel Wann
- Ascension Healthcare Wisconsin, Milwaukee, Wisconsin; Nuclear Cardiology Expert
| | | | | | - Suhny Abbara
- Specialty Chair, UT Southwestern Medical Center, Dallas, Texas
| |
Collapse
|
13
|
A Secondary Analysis to Identify Patient-Centered Outcomes in the ACR’s Appropriateness Criteria. J Am Coll Radiol 2019; 16:1645-1655. [DOI: 10.1016/j.jacr.2019.05.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 05/13/2019] [Accepted: 05/14/2019] [Indexed: 11/20/2022]
|
14
|
Invasive coronary angiography findings across the CAD-RADS classification spectrum. Int J Cardiovasc Imaging 2019; 35:1955-1961. [PMID: 31227952 DOI: 10.1007/s10554-019-01654-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 06/17/2019] [Indexed: 10/26/2022]
Abstract
The recently introduced coronary artery disease reporting and data system (CAD-RADS) evaluated by computed tomography and based on stenosis severity, might not adequately reflect the complexity of CAD. We explored the relationship between CAD-RADS and the spatial distribution, burden, and complexity of lesions by invasive coronary angiography (ICA). Stable patients who underwent coronary computed tomography angiography (CCTA) and ICA comprised the study population. Patients were classified according to the CAD-RADS: 0, No plaque; 1, 1-24% stenosis; 2, 25-49%; 3, 50-69%; 4A, 70-99%; 4B, left main stenosis or 3-vessel obstructive disease; and 5, total occlusion. Based on ICA findings, we calculated the SYNTAX score and the CAD extension index. Ninety-one patients were included, with a mean age of 61.4 ± 10.5 years (74% male). We found significant relationships between CAD-RADS and both the SYNTAX score (p < 0.0001) and the CAD extension index (p < 0.0001), although the complexity of coronary anatomy differed among patients with CAD-RADS ≥ 4A. Among patients with CAD-RADS < 4, the mean segment involvement score (SIS) was 8.4 ± 4.0, 52% of them with a SIS > 5. Of the 30 patients with CAD-RADS 5, 9 (30%) affected distal segments or secondary branches, and 9 (30%) had concomitant severe non-extensive disease at ICA. Regarding the spatial distribution of the non-occluded most severe lesions, 27 (44%) comprised distal segments or secondary branches. In the present study including a high-risk population, we identified diverse coronary anatomy complexity scenarios and relevant differences in spatial distribution sharing the same CAD-RADS classification.
Collapse
|
15
|
Verheij VA, Scholtz JE, Meyersohn NM, Parry BA, Hoffmann U, Ghoshhajra BB, Nagurney JT. Secondary cardiac risk stratifying tests after coronary computed tomography angiography in emergency department patients. J Cardiovasc Comput Tomogr 2018; 12:500-508. [PMID: 30340962 DOI: 10.1016/j.jcct.2018.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Revised: 09/15/2018] [Accepted: 10/02/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Several large trials demonstrated that coronary computed tomography angiography (CTA) in a triage strategy could lead to increased secondary cardiac risk stratifying testing (SCRST). Whether this is true for routine clinical care remains unclear. We measured SCRSTs after coronary CTA was implemented in our emergency department (ED) practice by CTA result, and if locally existing management recommendations for a structured post CTA diagnostic strategy were followed. METHODS This single site retrospective cohort study included all our ED patients who received coronary CTA between October 1, 2012 and September 30, 2016. SCRST's included functional cardiac tests and invasive coronary angiography (ICA), performed during the ED coronary CTA visit or related admission. RESULTS A total of 1916 subjects were included with a mean age of 52.9 ± 10.8 years. Of their coronary CTAs, 179 were positive (severe stenosis, occlusion or ventricular wall motion abnormalities; 9.3%), 105 intermediate (moderate stenosis; 5.5%), 1611 negative (no to mild obstructive CAD; 84.1%) and 21 non-diagnostic (1.1%). SCRSTs were performed in 237 (overall 12.4%, noninvasive in 5.6%, ICA in 6.7%). After positive coronary CTA, 73.7% of subjects received SCRSTs. For intermediate, negative and non-diagnostic CTAs this was 72.4%, 1.1% and 47.6% respectively. Management conformed to local management recommendations in 96.2% of cases. CONCLUSION In spite of previous trials, rates of secondary cardiac risk stratifying tests after routine clinical ED coronary CTA are low, especially in patients with negative coronary CTA. Structured management guidelines for post coronary CTA, and adherence to these guidelines, appear essential.
Collapse
Affiliation(s)
- Vincent A Verheij
- Department of Emergency Medicine, Massachusetts General Hospital & Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA.
| | - Jan-Erik Scholtz
- Cardiac MR PET CT Program, Department of Radiology and Division of Cardiology, Massachusetts General Hospital & Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA.
| | - Nandini M Meyersohn
- Cardiac MR PET CT Program, Department of Radiology and Division of Cardiology, Massachusetts General Hospital & Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA.
| | - Blair A Parry
- Department of Emergency Medicine and Division of Research, Massachusetts General Hospital, 5 Emerson Place, Boston, MA, 02114, USA.
| | - Udo Hoffmann
- Cardiac MR PET CT Program, Department of Radiology and Division of Cardiology, Massachusetts General Hospital & Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA.
| | - Brian B Ghoshhajra
- Cardiac MR PET CT Program, Department of Radiology and Division of Cardiology, Massachusetts General Hospital & Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA.
| | - John T Nagurney
- Department of Emergency Medicine, Massachusetts General Hospital & Harvard Medical School, 55 Fruit Street, Boston, MA, 02114, USA.
| |
Collapse
|
16
|
Abstract
Resting regional wall motion abnormality (RWMA) has significant prognostic value beyond the findings of computed tomography (CT) coronary angiography. Stretch quantification of endocardial engraved zones (SQUEEZ) has been proposed as a measure of regional cardiac function. The purpose of the work reported here was to determine the effect of lowering the radiation dose on the precision of automatic SQUEEZ assessments of RWMA. Chronic myocardial infarction was created by a 2-h occlusion of the left anterior descending coronary artery in 10 swine (heart rates 80-100, ejection fraction 25-57%). CT was performed 5-11 months post infarct using first-pass contrast enhanced segmented cardiac function scans on a 320-detector row scanner at 80 kVp/500 mA. Images were reconstructed at end diastole and end systole with both filtered back projection and using the "standard" adaptive iterative dose reduction (AIDR) algorithm. For each acquisition, 9 lower dose acquisitions were created. End systolic myocardial function maps were calculated using SQUEEZ for all noise levels and contrast-to-noise ratio (CNR) between the left ventricle blood and myocardium was calculated as a measure of image quality. For acquisitions with CNR > 4, SQUEEZ could be estimated with a precision of ± 0.04 (p < 0.001) or 5.7% of its dynamic range. The difference between SQUEEZ values calculated from AIDR and FBP images was not statistically significant. Regional wall motion abnormality can be quantified with good precision from low dose acquisitions, using SQUEEZ, as long as the blood-myocardium CNR stays above 4.
Collapse
|
17
|
Abstract
PURPOSE OF REVIEW To compare outcomes between registries and randomized controlled trials of coronary computed tomographic angiography (CCTA)-based versus standard of care approaches to the initial evaluation of patients with acute chest pain. RECENT FINDINGS Randomized trials have demonstrated CCTA to be a safe and efficient tool for triage of low- to intermediate-risk patients presenting to the emergency department with chest pain. Recent studies demonstrate heterogeneous result using different standard of care approaches for evaluation of hard endpoints in comparison with standard evaluation. Also, there has been continued concern for increase in subsequent testing after coronary CTA. Although CCTA improves detection of coronary artery disease, it is uncertain if it will bring improvement of long-term health outcomes at this point of time. Careful analysis of the previous results and further investigation will be required to validate evaluation of hard endpoints.
Collapse
|
18
|
Coronary CT Angiography: Use in Patients With Chest Pain Presenting to Emergency Departments. AJR Am J Roentgenol 2018; 210:816-820. [PMID: 29446681 DOI: 10.2214/ajr.17.18740] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Previously published reports have shown that coronary CT angiography (CCTA) is a more efficient method of diagnosis than myocardial perfusion imaging (MPI) and stress echocardiography for patients presenting to emergency departments (EDs) with acute chest pain. In light of this evidence, the objective of this study was to examine recent trends in the use of these techniques in EDs. MATERIALS AND METHODS The nationwide Medicare Part B databases for 2006-2015 were the data source. The Current Procedural Terminology, version 4, codes for CCTA, MPI, and stress echocardiography were selected. Medicare place-of-service codes were used to determine procedure volumes in EDs. Medicare specialty codes were used to ascertain how many of these examinations were interpreted by radiologists, cardiologists, and other physicians as a group. RESULTS From 2006 to 2015, there was essentially no change in the number of MPI examinations performed in EDs for patients using Medicare (22,342 in 2006, 22,338 in 2015) or in the number of stress echocardiograms (3544 in 2006, 3520 in 2015). By contrast, the number of CCTA examinations increased rapidly, from 126 in 2006 to 1919 in 2015 (compound annual growth rate, 35%). Despite this rapid growth, patients in EDs underwent 11.6 times as many MPI as CCTA examinations in 2015. In that last year of the study, radiologists interpreted 78% of ED MPI and 83% of ED CCTA examinations. CONCLUSION Use of CCTA in EDs has increased rapidly, but far more MPI examinations are still being performed. This finding suggests that recently acquired evidence is not yet being fully acted upon.
Collapse
|
19
|
Round-the-clock performance of coronary CT angiography for suspected acute coronary syndrome: Results from the BEACON trial. Eur Radiol 2017; 28:2169-2175. [PMID: 29247351 PMCID: PMC5882623 DOI: 10.1007/s00330-017-5082-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Revised: 09/03/2017] [Accepted: 09/13/2017] [Indexed: 12/15/2022]
Abstract
Objective To assess the image quality of coronary CT angiography (CCTA) for suspected acute coronary syndrome (ACS) outside office hours. Methods Patients with symptoms suggestive of an ACS underwent CCTA at the emergency department 24 hours, 7 days a week. A total of 118 patients, of whom 89 (75 %) presented during office hours (weekdays between 07:00 and 17:00) and 29 (25 %) outside office hours (weekdays between 17:00 and 07:00, weekends and holidays) underwent CCTA. Image quality was evaluated per coronary segment by two experienced readers and graded on an ordinal scale ranging from 1 to 3. Results There were no significant differences in acquisition parameters, beta-blocker administration or heart rate between patients presenting during office hours and outside office hours. The median quality score per patient was 30.5 [interquartile range 26.0–33.5] for patients presenting during office hours in comparison to 27.5 [19.75–32.0] for patients presenting outside office hours (p=0.043). The number of non-evaluable segments was lower for patients presenting during office hours (0 [0–1.0] vs. 1.0 [0–4.0], p=0.009). Conclusion Image quality of CCTA outside office hours in the diagnosis of suspected ACS is diminished. Key Points • Quality scores were higher for coronary-CTA during office hours. • There were no differences in acquisition parameters. • There was a non-significant trend towards higher heart rates outside office hours. • Coronary-CTA on the ED requires state-of-the-art scanner technology and sufficiently trained staff. • Coronary-CTA on the ED needs preparation time and optimisation of the procedure.
Collapse
|
20
|
Cury RC, Abbara S, Achenbach S, Agatston A, Berman DS, Budoff MJ, Dill KE, Jacobs JE, Maroules CD, Rubin GD, Rybicki FJ, Schoepf UJ, Shaw LJ, Stillman AE, White CS, Woodard PK, Leipsic JA. Coronary Artery Disease - Reporting and Data System (CAD-RADS): An Expert Consensus Document of SCCT, ACR and NASCI: Endorsed by the ACC. JACC Cardiovasc Imaging 2017; 9:1099-1113. [PMID: 27609151 DOI: 10.1016/j.jcmg.2016.05.005] [Citation(s) in RCA: 139] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 04/29/2016] [Accepted: 05/26/2016] [Indexed: 12/15/2022]
Abstract
The intent of CAD-RADS - Coronary Artery Disease Reporting and Data System is to create a standardized method to communicate findings of coronary CT angiography (coronary CTA) in order to facilitate decision-making regarding further patient management. The suggested CAD-RADS classification is applied on a per-patient basis and represents the highest-grade coronary artery lesion documented by coronary CTA. It ranges from CAD-RADS 0 (Zero) for the complete absence of stenosis and plaque to CAD-RADS 5 for the presence of at least one totally occluded coronary artery and should always be interpreted in conjunction with the impression found in the report. Specific recommendations are provided for further management of patients with stable or acute chest pain based on the CAD-RADS classification. The main goal of CAD-RADS is to standardize reporting of coronary CTA results and to facilitate communication of test results to referring physicians along with suggestions for subsequent patient management. In addition, CAD-RADS will provide a framework of standardization that may benefit education, research, peer-review and quality assurance with the potential to ultimately result in improved quality of care.
Collapse
|
21
|
Abstract
Coronary computed tomographic angiography has become a reliable diagnostic tool in the evaluation of patients with chest pain. Studies have shown this modality to be accurate and safe when compared with conventional methods of assessing patients with chest pain. We review the recent developments with coronary computed tomographic angiography and devote particular attention toward its application to triage patients in the emergency department.
Collapse
Affiliation(s)
- Nikhil Goyal
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA, USA
| | - Arthur Stillman
- Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA, USA
| |
Collapse
|
22
|
Ghoshhajra BB, Takx RAP, Staziaki PV, Vadvala H, Kim P, Neilan TG, Meyersohn NM, Bittner D, Janjua SA, Mayrhofer T, Greenwald JL, Truong QA, Abbara S, Brown DFM, Januzzi JL, Francis S, Nagurney JT, Hoffmann U. Clinical implementation of an emergency department coronary computed tomographic angiography protocol for triage of patients with suspected acute coronary syndrome. Eur Radiol 2017; 27:2784-2793. [PMID: 27885414 PMCID: PMC5976244 DOI: 10.1007/s00330-016-4562-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 08/03/2016] [Accepted: 08/11/2016] [Indexed: 12/27/2022]
Abstract
OBJECTIVES To evaluate the efficiency and safety of emergency department (ED) coronary computed tomography angiography (CTA) during a 3-year clinical experience. METHODS Single-center registry of coronary CTA in consecutive ED patients with suspicion of acute coronary syndrome (ACS). The primary outcome was efficiency of coronary CTA defined as the length of hospitalization. Secondary endpoints of safety were defined as the rate of downstream testing, normalcy rates of invasive coronary angiography (ICA), absence of missed ACS, and major adverse cardiac events (MACE) during follow-up, and index radiation exposure. RESULTS One thousand twenty two consecutive patients were referred for clinical coronary CTA with suspicion of ACS. Overall, median time to discharge home was 10.5 (5.7-24.1) hours. Patient disposition was 42.7 % direct discharge from the ED, 43.2 % discharge from emergency unit, and 14.1 % hospital admission. ACS rate during index hospitalization was 9.1 %. One hundred ninety two patients underwent additional diagnostic imaging and 77 underwent ICA. The positive predictive value of CTA compared to ICA was 78.9 % (95 %-CI 68.1-87.5 %). Median CT radiation exposure was 4.0 (2.5-5.8) mSv. No ACS was missed; MACE at follow-up after negative CTA was 0.2 %. CONCLUSIONS Coronary CTA in an experienced tertiary care setting allows for efficient and safe management of patients with suspicion for ACS. KEY POINTS • ED Coronary CTA using advanced systems is associated with low radiation exposure. • Negative coronary CTA is associated with low rates of MACE. • CTA in ED patients enables short median time to discharge home. • CTA strategy is characterized by few downstream tests including unnecessary ICA.
Collapse
Affiliation(s)
- Brian B Ghoshhajra
- Cardiac MR PET CT Program, Department of Radiology (Cardiovascular Imaging) and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114-2750, USA.
| | - Richard A P Takx
- Cardiac MR PET CT Program, Department of Radiology (Cardiovascular Imaging) and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114-2750, USA
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Pedro V Staziaki
- Cardiac MR PET CT Program, Department of Radiology (Cardiovascular Imaging) and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114-2750, USA
| | - Harshna Vadvala
- Cardiac MR PET CT Program, Department of Radiology (Cardiovascular Imaging) and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114-2750, USA
| | - Phillip Kim
- Cardiac MR PET CT Program, Department of Radiology (Cardiovascular Imaging) and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114-2750, USA
| | - Tomas G Neilan
- Cardiac MR PET CT Program, Department of Radiology (Cardiovascular Imaging) and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114-2750, USA
- Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Nandini M Meyersohn
- Cardiac MR PET CT Program, Department of Radiology (Cardiovascular Imaging) and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114-2750, USA
| | - Daniel Bittner
- Cardiac MR PET CT Program, Department of Radiology (Cardiovascular Imaging) and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114-2750, USA
- Friedrich-Alexander University Erlangen-Nürnberg (FAU), Department of Medicine 2 - Cardiology, University Hospital Erlangen, Erlangen, Germany
| | - Sumbal A Janjua
- Cardiac MR PET CT Program, Department of Radiology (Cardiovascular Imaging) and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114-2750, USA
| | - Thomas Mayrhofer
- Cardiac MR PET CT Program, Department of Radiology (Cardiovascular Imaging) and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114-2750, USA
- School of Business Studies, Stralsund University of Applied Sciences, Stralsund, Germany
| | - Jeffrey L Greenwald
- Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Quyhn A Truong
- Cardiac MR PET CT Program, Department of Radiology (Cardiovascular Imaging) and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114-2750, USA
- Department of Radiology, Weill Cornell College of Medicine, New York, NY, USA
| | - Suhny Abbara
- Cardiac MR PET CT Program, Department of Radiology (Cardiovascular Imaging) and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114-2750, USA
- Department Cardiothoracic Imaging, UT Southwestern Medical Center, Dallas, TX, USA
| | - David F M Brown
- Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - James L Januzzi
- Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Sanjeev Francis
- Cardiac MR PET CT Program, Department of Radiology (Cardiovascular Imaging) and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114-2750, USA
- Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - John T Nagurney
- Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Udo Hoffmann
- Cardiac MR PET CT Program, Department of Radiology (Cardiovascular Imaging) and Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, 165 Cambridge Street, Suite 400, Boston, MA, 02114-2750, USA
| |
Collapse
|
23
|
Non-gated high-pitch computed tomography aortic angiography: Myocardial perfusion defects in patients with suspected aortic dissection. J Cardiovasc Comput Tomogr 2017; 11:208-212. [DOI: 10.1016/j.jcct.2017.04.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 03/20/2017] [Accepted: 04/11/2017] [Indexed: 11/22/2022]
|
24
|
Abstract
Coronary computed tomography angiography (CCTA) plays an important role in many specific scenarios such as in symptomatic patients with intermediate pretest of coronary artery disease (CAD), as well as in the triage of patients with acute chest pain with TIMI risk ≤2. However, it cannot detect the presence of associated ischemia, which is critical for clinical decision making among patients with moderate to severe stenosis. Although functional information can be obtained with different non-invasive tools, cardiac CT is the unique modality that can perform a comprehensive evaluation of coronary anatomy plus the functional significance of lesions. Myocardial CT perfusion (CTP) can be performed with different approaches such as static and dynamic CTP. In addition, static CTP can be performed using single energy CT (SECT) or dual energy CT (DECT). In this review, we will discuss the technical parameters and the available clinical evidence of static CTP using both SECT and DECT.
Collapse
Affiliation(s)
- Patricia Carrascosa
- Department of Cardiovascular Imaging, Diagnóstico Maipú, Buenos Aires, Argentina
| | - Carlos Capunay
- Department of Cardiovascular Imaging, Diagnóstico Maipú, Buenos Aires, Argentina
| |
Collapse
|
25
|
Meyersohn NM, Szilveszter B, Staziaki PV, Scholtz JE, Takx RAP, Hoffmann U, Ghoshhajra BB. Coronary CT angiography in the emergency department utilizing second and third generation dual source CT. J Cardiovasc Comput Tomogr 2017; 11:249-257. [PMID: 28506470 DOI: 10.1016/j.jcct.2017.03.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 03/17/2017] [Accepted: 03/19/2017] [Indexed: 01/28/2023]
Abstract
BACKGROUND Coronary computed tomography angiography (coronary CTA) allows efficient triage of low to intermediate risk patients with suspected acute coronary syndrome (ACS) in the emergency department (ED). Techniques for coronary CTA acquisition in the ED continue to evolve with the establishment of standardized scan protocols and the introduction of newer generations of CT hardware. OBJECTIVES To evaluate qualitative and quantitative image quality and radiation dose exposure of coronary CTA acquired on 2nd versus 3rd generation dual source CT (DSCT) scanners using a standardized institutional scan protocol designed for the ED. METHODS A retrospective observational case-control study was performed of 246 ED patients referred to coronary CTA with suspicion of ACS (56.5% male; mean age 53.3 ± 11.6 years) between October 2013 and August 2015.123 consecutive patients were scanned on 3rd generation DSCT, and a cohort of 123 patients matched by age, BMI and heart rate were identified who had undergone 2nd generation DSCT imaging utilizing the same standard clinical protocol. Qualitative and quantitative image quality parameters and radiation exposures were evaluated. RESULTS Qualitative image quality was significantly higher using 3rd generation DSCT as compared to 2nd generation (p < 0.001). Mean attenuation in the proximal coronary arteries was also significantly higher on 3rd generation DSCT than for 2nd generation (586 HU vs. 426 HU in the left main coronary artery (LM), p < 0.001). Signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) values, however, were lower in 3rd generation DSCT than 2nd generation (SNR 11.2 [9.9-13.4] vs 13.5 [11.0-15.5] and CNR 12.4 [10.9-14.8] vs 15.2 [12.8-17.9] in the LM, p < 0.001). Median effective dose was also lower for 3rd generation DSCT than for 2nd generation (2.9 [2.3-5.0] mSv and 3.7 mSv [2.5-5.7], respectively) although this trend did not reach statistical significance (p = 0.065). CONCLUSION Qualitative image quality and mean CT attenuation values of the assessed coronary segments were significantly higher using 3rd generation DSCT. SNR and CNR were lower on 3rd generation DSCT, however this was accompanied by a trend toward lower radiation dose exposure when using the same standard institutional protocol.
Collapse
Affiliation(s)
- Nandini M Meyersohn
- Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Department of Radiology, Massachusetts General Hospital, Boston, MA, USA.
| | - Balint Szilveszter
- Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Pedro V Staziaki
- Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Jan-Erik Scholtz
- Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Richard A P Takx
- Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Udo Hoffmann
- Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Brian B Ghoshhajra
- Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA; Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| |
Collapse
|
26
|
The Potential Role of Combined Highly Sensitive Troponin and Coronary Computed Tomography Angiography in the Evaluation of Patients with Suspected Acute Coronary Syndrome in the Emergency Department. CURRENT CARDIOVASCULAR IMAGING REPORTS 2016. [DOI: 10.1007/s12410-016-9393-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
27
|
Chinnaiyan KM, Raff GL. Coronary CT Angiography in the Emergency Department: Current Status. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2016; 18:62. [DOI: 10.1007/s11936-016-0484-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
|
28
|
Morris JR, Bellolio MF, Sangaralingham LR, Schilz SR, Shah ND, Goyal DG, Bell MR, Kopecky SL, Gilani WI, Hess EP. Comparative Trends and Downstream Outcomes of Coronary Computed Tomography Angiography and Cardiac Stress Testing in Emergency Department Patients With Chest Pain: An Administrative Claims Analysis. Acad Emerg Med 2016; 23:1022-30. [PMID: 27155236 DOI: 10.1111/acem.13005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Revised: 04/26/2016] [Accepted: 04/27/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Coronary computerized tomography angiography (CCTA) is a rapidly emerging technology for the evaluation of chest pain in the emergency department (ED). We assessed trends in CCTA use and compared downstream healthcare utilization between CCTA and cardiac stress testing modalities. METHODS Using administrative claims data (Optum Labs Data Warehouse) from over 100 million geographically diverse privately insured and Medicare Advantage enrollees across the United States, we identified 2,047,799 ED patients from January 2006 to December 2013 who presented with chest pain and had a CCTA or cardiac stress test within 72 hours. Cohorts were established based on CCTA or functional stress testing (myocardial perfusion scintigraphy [MPS], stress echocardiogram [SE], or treadmill exercise electrocardiogram [TMET]) performed within 72 hours of the ED visit. We tracked subsequent invasive cardiac procedures (invasive coronary angiography [ICA], percutaneous coronary intervention [PCI], and coronary artery bypass grafting [CABG]), repeat noninvasive testing, return ED visits, hospitalization, and the rate of acute myocardial infarction (AMI) within 30 days. We used propensity-score matching to adjust for coronary artery disease (CAD) risk factors, Charlson-Deyo comorbidity index, and baseline differences between patients selected for CCTA or cardiac stress testing. Logistic regression was used to measure adjusted associations between testing modality and outcomes. RESULTS During the study period, CCTA use increased from 0.8% to 4.5% of all cardiac testing within 72 hours, a change of 434% (p-value for trend < 0.001), while rates of other cardiac stress testing modalities decreased (-22% for TMET [p < 0.001]; -11% for SE [p = 0.11]; -6% for MPS [p = 0.04]. After matching, there was no difference in the 30-day rate of AMI between testing modalities. Compared to MPS, CCTA was associated with higher rates of PCI (odds ratio [OR] = 1.25, 95% confidence interval [CI] = 1.04 to 1.51), and CABG (OR = 1.47; 95% CI = 1.03 to 2.13). Compared to SE and treadmill stress testing, CCTA was associated with more invasive procedures, hospitalizations, return ED visits, and repeat noninvasive testing. CONCLUSIONS CCTA use increased fourfold during the study period and was associated with higher rates of PCI, CABG, repeat noninvasive testing, hospitalization, and return ED visits. The authors have no relevant financial information or potential conflicts to disclose.
Collapse
Affiliation(s)
- Jacob R Morris
- Mayo Medical School, Mayo Clinic College of Medicine, Rochester, MN
| | - M Fernanda Bellolio
- Division of Emergency Medicine Research, Department of Emergency Medicine, Mayo Clinic, Rochester, MN
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, MN
| | - Lindsey R Sangaralingham
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, MN
- Division of Healthcare Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Stephanie R Schilz
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, MN
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Nilay D Shah
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, MN
- Division of Healthcare Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN
- Optum Labs, Cambridge, MA
| | - Deepi G Goyal
- Division of Emergency Medicine Research, Department of Emergency Medicine, Mayo Clinic, Rochester, MN
| | | | | | - Waqas I Gilani
- Division of Emergency Medicine Research, Department of Emergency Medicine, Mayo Clinic, Rochester, MN
| | - Erik P Hess
- Division of Emergency Medicine Research, Department of Emergency Medicine, Mayo Clinic, Rochester, MN.
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, MN.
- Division of Healthcare Policy and Research, Department of Health Sciences Research, Mayo Clinic, Rochester, MN.
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, MN.
| |
Collapse
|
29
|
Ferencik M, Hoffmann U, Bamberg F, Januzzi JL. Highly sensitive troponin and coronary computed tomography angiography in the evaluation of suspected acute coronary syndrome in the emergency department. Eur Heart J 2016; 37:2397-405. [PMID: 26843275 PMCID: PMC6279199 DOI: 10.1093/eurheartj/ehw005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 12/16/2015] [Accepted: 01/05/2016] [Indexed: 02/02/2023] Open
Abstract
The evaluation of patients presenting to the emergency department with suspected acute coronary syndrome (ACS) remains a clinical challenge. The traditional assessment includes clinical risk assessment based on cardiovascular risk factors with serial electrocardiograms and cardiac troponin measurements, often followed by advanced cardiac testing as inpatient or outpatient (i.e. stress testing, imaging). Despite this costly and lengthy work-up, there is a non-negligible rate of missed ACS with an increased risk of death. There is a clinical need for diagnostic strategies that will lead to rapid and reliable triage of patients with suspected ACS. We provide an overview of the evidence for the role of highly sensitive troponin (hsTn) in the rapid and efficient evaluation of suspected ACS. Results of recent research studies have led to the introduction of hsTn with rapid rule-in and rule-out protocols into the guidelines. Highly sensitive troponin increases the sensitivity for the detection of myocardial infarction and decreases time to diagnosis; however, it may decrease the specificity, especially when used as a dichotomous variable, rather than continuous variable as recommended by guidelines; this may increase clinician uncertainty. We summarize the evidence for the use of coronary computed tomography angiography (CTA) as the rapid diagnostic tool in this population when used with conventional troponin assays. Coronary CTA significantly decreases time to diagnosis and discharge in patients with suspected ACS, while being safe. However, it may lead to increase in invasive procedures and includes radiation exposure. Finally, we outline the opportunities for the combined use of hsTn and coronary CTA that may result in increased efficiency, decreased need for imaging, lower cost, and decreased radiation dose.
Collapse
Affiliation(s)
- Maros Ferencik
- Knight Cardiovascular Institute, Oregon Health and Science University, 3180 SW Sam Jackson Park Road, Mail Code UHN62, Portland, OR 97239, USA Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Udo Hoffmann
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Fabian Bamberg
- Department of Radiology, University of Tuebingen, Tuebingen, Germany
| | - James L Januzzi
- Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| |
Collapse
|
30
|
Cury RC, Abbara S, Achenbach S, Agatston A, Berman DS, Budoff MJ, Dill KE, Jacobs JE, Maroules CD, Rubin GD, Rybicki FJ, Schoepf UJ, Shaw LJ, Stillman AE, White CS, Woodard PK, Leipsic JA. CAD-RADS™: Coronary Artery Disease - Reporting and Data System: An Expert Consensus Document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Radiology (ACR) and the North American Society for Cardiovascular Imaging (NASCI). Endorsed by the American College of Cardiology. J Am Coll Radiol 2016; 13:1458-1466.e9. [PMID: 27318576 DOI: 10.1016/j.jacr.2016.04.024] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 04/24/2016] [Indexed: 02/07/2023]
Abstract
The intent of CAD-RADS - Coronary Artery Disease Reporting and Data System is to create a standardized method to communicate findings of coronary CT angiography (coronary CTA) in order to facilitate decision-making regarding further patient management. The suggested CAD-RADS classification is applied on a per-patient basis and represents the highest-grade coronary artery lesion documented by coronary CTA. It ranges from CAD-RADS 0 (Zero) for the complete absence of stenosis and plaque to CAD-RADS 5 for the presence of at least one totally occluded coronary artery and should always be interpreted in conjunction with the impression found in the report. Specific recommendations are provided for further management of patients with stable or acute chest pain based on the CAD-RADS classification. The main goal of CAD-RADS is to standardize reporting of coronary CTA results and to facilitate communication of test results to referring physicians along with suggestions for subsequent patient management. In addition, CAD-RADS will provide a framework of standardization that may benefit education, research, peer-review and quality assurance with the potential to ultimately result in improved quality of care.
Collapse
Affiliation(s)
- Ricardo C Cury
- Miami Cardiac and Vascular Institute, Baptist Hospital of Miami, 8900 N Kendall Drive, Miami, FL, 33176, United States.
| | - Suhny Abbara
- Department of Radiology, 5323 Harry Hines Blvd, Dallas, TX, 75390, United States.
| | - Stephan Achenbach
- Friedrich-Alexander-Universität, Erlangen-Nürnberg, Department of Cardiology, Ulmenweg 18, 90154, Erlangen, Germany.
| | - Arthur Agatston
- Baptist Health Medical Grp, 1691 Michigan Avenue, Miami, FL, 33139, United States.
| | - Daniel S Berman
- Cedars-Sinai Med Center, 8700 Beverly Boulevard, Taper Building, Rm 1258, Los Angeles, CA, 90048, United States.
| | | | - Karin E Dill
- 5841 South Maryland Ave, MC2026, Chicago, IL, 60637, United States.
| | - Jill E Jacobs
- 550 First Avenue, New York, NY, 10016, United States.
| | | | - Geoffrey D Rubin
- 2400 Pratt Street, Room 8020, DCRI Box 17969, Durham, NC, 27715, United States.
| | - Frank J Rybicki
- The Ottawa Hospital General Campus, 501 Smyth Rd, Ottawa, ON, CA K1H 8L6, Canada.
| | | | - Leslee J Shaw
- 1256 Briarcliff Rd. NE, Rm 529, Atlanta, GA, 30324, United States.
| | | | - Charles S White
- University of Maryland, 22 S. Greene St., Baltimore, MD, 21201, United States.
| | - Pamela K Woodard
- Mallinckrodt Instit of Radiology, 510 S Kingshighway Blvd, St. Louis, MO, 63110, United States.
| | - Jonathon A Leipsic
- Department of Radiology, St. Paul's Hospital, 2nd Floor, Providence Building, 1081 Burrard Street, Vancouver, BC, V6Z 1Y6, United States.
| |
Collapse
|
31
|
CAD-RADS(TM) Coronary Artery Disease - Reporting and Data System. An expert consensus document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Radiology (ACR) and the North American Society for Cardiovascular Imaging (NASCI). Endorsed by the American College of Cardiology. J Cardiovasc Comput Tomogr 2016; 10:269-81. [PMID: 27318587 DOI: 10.1016/j.jcct.2016.04.005] [Citation(s) in RCA: 424] [Impact Index Per Article: 53.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 04/20/2016] [Accepted: 04/28/2016] [Indexed: 01/01/2023]
Abstract
The intent of CAD-RADS - Coronary Artery Disease Reporting and Data System is to create a standardized method to communicate findings of coronary CT angiography (coronary CTA) in order to facilitate decision-making regarding further patient management. The suggested CAD-RADS classification is applied on a per-patient basis and represents the highest-grade coronary artery lesion documented by coronary CTA. It ranges from CAD-RADS 0 (Zero) for the complete absence of stenosis and plaque to CAD-RADS 5 for the presence of at least one totally occluded coronary artery and should always be interpreted in conjunction with the impression found in the report. Specific recommendations are provided for further management of patients with stable or acute chest pain based on the CAD-RADS classification. The main goal of CAD-RADS is to standardize reporting of coronary CTA results and to facilitate communication of test results to referring physicians along with suggestions for subsequent patient management. In addition, CAD-RADS will provide a framework of standardization that may benefit education, research, peer-review and quality assurance with the potential to ultimately result in improved quality of care.
Collapse
|
32
|
Kruk M, Wardziak Ł, Demkow M, Pleban W, Pręgowski J, Dzielińska Z, Witulski M, Witkowski A, Rużyłło W, Kępka C. Workstation-Based Calculation of CTA-Based FFR for Intermediate Stenosis. JACC Cardiovasc Imaging 2016; 9:690-9. [PMID: 26897667 DOI: 10.1016/j.jcmg.2015.09.019] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 09/17/2015] [Accepted: 09/17/2015] [Indexed: 11/16/2022]
Abstract
OBJECTIVES This study sought to evaluate the proportion of patients with intermediate coronary stenosis diagnosed on computed tomography angiography (CTA), which may be saved from any further testing due to use of CTA-based fractional flow reserve (FFR). BACKGROUND Coronary CTA often results in diagnosis of intermediate stenosis, triggering further physiological testing. CTA-based FFR (CTA-FFR) is a promising diagnostic tool, which may obviate the need for further testing. However, the specific thresholds for CTA-FFR values predicting ischemic versus nonischemic FFR with acceptable confidence are unknown, obscuring clinical utility of the diagnostic strategy using CTA-FFR. METHODS We analyzed 96 lesions (mean CTA stenosis: 69.7 ± 11.7%) in 90 patients (63.4 ± 8.2 years, 32% were men) who underwent CTA for suspected CAD and were diagnosed with at least 1 intermediate coronary stenosis (50% to 90%) scheduled for further physiological testing. All patients underwent routine invasive FFR and CTA-FFR evaluation. The objective was to determine the proportion of patients falling between the lower and upper CTA-FFR thresholds that predict ischemic and nonischemic stenosis, respectively (on the basis of an invasive FFR cutpoint of ≤0.80), with ≥90% accuracy. RESULTS The invasive FFR ≤0.8 was observed in 41 of 96 lesions (42.7%). According to Bland-Altman analysis, the CTA-FFR underestimated FFR by 0.01 and the 95% limits of agreement were ±0.19. Receiver-operating characteristic area under the curve was significantly higher for CTA-FFR than that for CTA (per lesion 0.835 vs. 0.660, respectively; p = 0.007). The CTA-FFR thresholds for which the positive and negative predictive values were each ≥90% (corresponding to an FFR of ≤0.80) were >0.87 or <0.74, respectively, encompassing 49 lesions (51%) and 45 of 90 patients. CONCLUSIONS In around one-half of the patients diagnosed with intermediate stenosis, coronary CTA-based FFR may confidently discriminate between ischemic versus nonischemic stenoses. Our findings require validation in an independent cohort.
Collapse
Affiliation(s)
- Mariusz Kruk
- Coronary Artery and Structural Heart Disease Department, Institute of Cardiology, Warsaw, Poland.
| | - Łukasz Wardziak
- Coronary Artery and Structural Heart Disease Department, Institute of Cardiology, Warsaw, Poland
| | - Marcin Demkow
- Coronary Artery and Structural Heart Disease Department, Institute of Cardiology, Warsaw, Poland
| | - Weronika Pleban
- Coronary Artery and Structural Heart Disease Department, Institute of Cardiology, Warsaw, Poland
| | - Jerzy Pręgowski
- Interventional Cardiology and Angiology Department, Institute of Cardiology, Warsaw, Poland
| | - Zofia Dzielińska
- Coronary Artery and Structural Heart Disease Department, Institute of Cardiology, Warsaw, Poland
| | | | - Adam Witkowski
- Interventional Cardiology and Angiology Department, Institute of Cardiology, Warsaw, Poland
| | - Witold Rużyłło
- Coronary Artery and Structural Heart Disease Department, Institute of Cardiology, Warsaw, Poland
| | - Cezary Kępka
- Coronary Artery and Structural Heart Disease Department, Institute of Cardiology, Warsaw, Poland
| |
Collapse
|
33
|
Pourmorteza A, Chen MY, van der Pals J, Arai AE, McVeigh ER. Correlation of CT-based regional cardiac function (SQUEEZ) with myocardial strain calculated from tagged MRI: an experimental study. Int J Cardiovasc Imaging 2015; 32:817-23. [PMID: 26706935 DOI: 10.1007/s10554-015-0831-7] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Accepted: 12/22/2015] [Indexed: 01/02/2023]
Abstract
The objective of this study was to investigate the correlation between local myocardial function estimates from CT and myocardial strain from tagged MRI in the same heart. Accurate detection of regional myocardial dysfunction can be an important finding in the diagnosis of functionally significant coronary artery disease. Tagged MRI is currently a reference standard for noninvasive regional myocardial function analysis; however, it has practical drawbacks. We have developed a CT imaging protocol and automated image analysis algorithm for estimating regional cardiac function from a few heartbeats. This method tracks the motion of the left ventricular (LV) endocardial surface to produce local function maps: we call the method Stretch Quantification of Endocardial Engraved Zones (SQUEEZ). Myocardial infarction was created by ligation of the left anterior descending coronary artery for 2 h followed by reperfusion in canine models. Tagged and cine MRI scans were performed during the reperfusion phase and first-pass contrast enhanced CT scans were acquired. The average delay between the CT and MRI scans was <1 h. Circumferential myocardial strain (Ecc) was calculated from the tagged MRI data. The agreement between peak systolic Ecc and SQUEEZ was investigated in 162 segments in the 9 hearts. Linear regression and Bland-Altman analysis was used to assess the correlation between the two metrics of local LV function. The results show good agreement between SQUEEZ and Ecc: (r = 0.71, slope = 0.78, p < 0.001). Furthermore, Bland-Altman showed a small bias of -0.02 with 95 % confidence interval of 0.1, and standard deviation of 0.05 representing ~6.5 % of the dynamic range of LV function. The good agreement between the estimates of local myocardial function obtained from CT SQUEEZ and tagged MRI provides encouragement to investigate the use of SQUEEZ for measuring regional cardiac function at a low clinical dose in humans.
Collapse
Affiliation(s)
- Amir Pourmorteza
- Department of Radiology and Imaging Sciences, National Institutes of Health Clinical Center, Bethesda, MD, USA.
| | - Marcus Y Chen
- Advanced Cardiovascular Imaging Laboratory, Cardiopulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Jesper van der Pals
- Advanced Cardiovascular Imaging Laboratory, Cardiopulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Andrew E Arai
- Advanced Cardiovascular Imaging Laboratory, Cardiopulmonary Branch, National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Elliot R McVeigh
- Departments of Bioengineering, Medicine, and Radiology, University of California, San Diego, San Diego, CA, USA
| |
Collapse
|
34
|
ACR Appropriateness Criteria Acute Nonspecific Chest Pain—Low Probability of Coronary Artery Disease. J Am Coll Radiol 2015; 12:1266-71. [DOI: 10.1016/j.jacr.2015.09.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 09/03/2015] [Indexed: 11/24/2022]
|
35
|
Nikolaou N, Arntz H, Bellou A, Beygui F, Bossaert L, Cariou A. Das initiale Management des akuten Koronarsyndroms. Notf Rett Med 2015. [DOI: 10.1007/s10049-015-0084-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
|
36
|
Nikolaou NI, Arntz HR, Bellou A, Beygui F, Bossaert LL, Cariou A, Danchin N. European Resuscitation Council Guidelines for Resuscitation 2015 Section 8. Initial management of acute coronary syndromes. Resuscitation 2015; 95:264-77. [DOI: 10.1016/j.resuscitation.2015.07.030] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
|
37
|
Lee NJ, Litt H. Cardiac CT angiography for evaluation of acute chest pain. Int J Cardiovasc Imaging 2015; 32:101-12. [PMID: 26342713 DOI: 10.1007/s10554-015-0763-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 08/31/2015] [Indexed: 01/23/2023]
Abstract
Chest pain is the second most common emergency department (ED) presentation in the United States. Cardiac computed tomography angiography (CCTA) now plays an important role in the evaluation of patients with suspected acute coronary syndrome in the ED setting. In this article, we review the available techniques focused on the use of CCTA to evaluate patients fosr coronary atherosclerosis for timely triage of acute chest pain.
Collapse
Affiliation(s)
- Nam Ju Lee
- Department of Radiology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
| | - Harold Litt
- Department of Radiology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA.
| |
Collapse
|
38
|
Maroules CD, Cury RC, Ghoshhajra BB, Hoffmann U, Litt HI, Blankstein R, Abbara S. Strategy for Building a Successful Coronary CT Angiography Program in the Emergency Department. CURRENT CARDIOVASCULAR IMAGING REPORTS 2015. [DOI: 10.1007/s12410-015-9337-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
39
|
Updates on Coronary CTA in the Emergency Department. CURRENT RADIOLOGY REPORTS 2015. [DOI: 10.1007/s40134-015-0096-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
40
|
Schlett CL, Hoffmann U, Geisler T, Nikolaou K, Bamberg F. Cardiac computed tomography for the evaluation of the acute chest pain syndrome: state of the art. Radiol Clin North Am 2015; 53:297-305. [PMID: 25726995 DOI: 10.1016/j.rcl.2014.11.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Coronary computed tomography angiography (CCTA) is recommended for the triage of acute chest pain in patients with a low-to-intermediate likelihood for acute coronary syndrome. Absence of coronary artery disease (CAD) confirmed by CCTA allows rapid emergency department discharge. This article shows that CCTA-based triage is as safe as traditional triage, reduces the hospital length of stay, and may provide cost-effective or even cost-saving care.
Collapse
Affiliation(s)
- Christopher L Schlett
- Department of Diagnostic and Interventional Radiology, University Hospital Heidelberg, Im Neuenheimer Feld 110, Heidelberg 69120, Germany; Cardiac MR PET CT Program, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge St, Suite 400, Boston, MA 02114, USA
| | - Udo Hoffmann
- Cardiac MR PET CT Program, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge St, Suite 400, Boston, MA 02114, USA
| | - Tobias Geisler
- Department of Cardiology and Cardiovascular Medicine University Hospital of Tübingen, Hoppe-Seyler-Straβe 3, Tübingen 72076, Germany
| | - Konstantin Nikolaou
- Department of Diagnostic and Interventional Radiology, University Hospital of Tübingen, Hoppe-Seyler-Straβe 3, Tübingen 72076, Germany
| | - Fabian Bamberg
- Cardiac MR PET CT Program, Massachusetts General Hospital, Harvard Medical School, 165 Cambridge St, Suite 400, Boston, MA 02114, USA; Department of Diagnostic and Interventional Radiology, University Hospital of Tübingen, Hoppe-Seyler-Straβe 3, Tübingen 72076, Germany.
| |
Collapse
|
41
|
Cury RC. President's page: Implementation of coronary CT angiography to assess chest pain patients in the Emergency Department – A Call for Action! J Cardiovasc Comput Tomogr 2015; 9:156-7. [DOI: 10.1016/j.jcct.2015.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
42
|
|
43
|
Affiliation(s)
- Ricardo C Cury
- Miami Cardiac and Vascular Institute, Baptist Hospital of South Florida, 8900 North Kendall Drive, Miami, FL 33176, USA
| |
Collapse
|
44
|
Raff GL, Chinnaiyan KM, Cury RC, Garcia MT, Hecht HS, Hollander JE, O'Neil B, Taylor AJ, Hoffmann U. SCCT guidelines on the use of coronary computed tomographic angiography for patients presenting with acute chest pain to the emergency department: A Report of the Society of Cardiovascular Computed Tomography Guidelines Committee. J Cardiovasc Comput Tomogr 2014; 8:254-71. [DOI: 10.1016/j.jcct.2014.06.002] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 06/04/2014] [Indexed: 02/06/2023]
|
45
|
Diagnostic Performance of Algorithm for Computer-Assisted Detection of Significant Coronary Artery Disease in Patients With Acute Chest Pain: Comparison With Invasive Coronary Angiography. AJR Am J Roentgenol 2014; 202:730-7. [DOI: 10.2214/ajr.13.11419] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|
46
|
Poon M, Cortegiano M, Abramowicz AJ, Hines M, Singer AJ, Henry MC, Viccellio P, Hellinger JC, Ferraro S, Poon A, Raff GL, Voros S, Farkouh ME, Noack P. Associations Between Routine Coronary Computed Tomographic Angiography and Reduced Unnecessary Hospital Admissions, Length of Stay, Recidivism Rates, and Invasive Coronary Angiography in the Emergency Department Triage of Chest Pain. J Am Coll Cardiol 2013; 62:543-52. [PMID: 23684682 DOI: 10.1016/j.jacc.2013.04.040] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 04/27/2013] [Accepted: 04/29/2013] [Indexed: 10/26/2022]
|
47
|
Lesser JR. President's page: Why are some cardiac CT programs successful? J Cardiovasc Comput Tomogr 2013; 7:211-2. [PMID: 23849495 DOI: 10.1016/j.jcct.2013.05.006] [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: 05/30/2013] [Accepted: 05/31/2013] [Indexed: 10/26/2022]
Affiliation(s)
- John R Lesser
- Minneapolis Heart Institute, Abbott Northwestern Hospital, Minneapolis, MN, USA
| |
Collapse
|
48
|
Bilolikar AN, Chinnaiyan KM. Coronary CT Angiography in the Emergency Department: Current Status. CURRENT CARDIOVASCULAR IMAGING REPORTS 2013. [DOI: 10.1007/s12410-013-9196-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
49
|
Maroules CD, Blaha MJ, El-Haddad MA, Ferencik M, Cury RC. Establishing a successful coronary CT angiography program in the emergency department: Official writing of the Fellow and Resident Leaders of the Society of Cardiovascular Computed Tomography (FiRST). J Cardiovasc Comput Tomogr 2013; 7:150-6. [DOI: 10.1016/j.jcct.2013.05.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2012] [Revised: 03/08/2013] [Accepted: 05/26/2013] [Indexed: 10/26/2022]
|
50
|
Cury RC, Budoff M, Taylor AJ. Coronary CT angiography versus standard of care for assessment of chest pain in the emergency department. J Cardiovasc Comput Tomogr 2013; 7:79-82. [DOI: 10.1016/j.jcct.2013.01.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2012] [Revised: 01/11/2013] [Accepted: 01/12/2013] [Indexed: 11/26/2022]
|