CT coronary angiography in low-risk, acute chest pain. Nat Rev Cardiol 9, — Download citation. Published : 04 September Issue Date : November Anyone you share the following link with will be able to read this content:. Sorry, a shareable link is not currently available for this article. Provided by the Springer Nature SharedIt content-sharing initiative.
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Skip to main content Thank you for visiting nature. Subjects Coronary artery disease and stable angina Pain Radiography. Access through your institution. Buy or subscribe. This is a preview of subscription content. Change institution. Buy article Get time limited or full article access on ReadCube. Figure 1: Bayes' theorem for diagnostic accuracy. References 1 Hoffmann, U. Article Google Scholar 5 Goldstein, J. Article Google Scholar 6 Goldstein, J.
Article Google Scholar 7 Choi, E. Article Google Scholar 8 Schlett, C. Article Google Scholar 9 Koo, B. Raff reported, is the fact that many patients in the standard evaluation group underwent no tests—a practice that is not evidence-based, he noted. With regard to the potential for increased radiation exposure with CTA, Dr. Budoff observed that the technology is evolving rapidly, with dosages decreasing significantly every year.
Moreover, he noted, CTA typically delivers less radiation than a nuclear stress test, which in many parts of the country is the most commonly used alternative for evaluating chest pain. Budoff stressed the need to assess the longer-term impact of CTA screening on repeat hospitalizations and costs.
Raff made the same point. Patients with normal CT scans are highly unlikely to have CAD and do not need further tests, he explained, while those who pass a stress test often return to the emergency department for repeat tests and ultimately undergo angiography. There was no difference in baseline demographics and clinical characteristics between the CTA and standard evaluation groups. To ensure that cases of ACS did not go undetected, patients discharged within 24 hours of presentation to the emergency department were contacted within 72 hours and at 28 days post discharge.
Before the start of the study, participating sites were not routinely performing CTA in the emergency department to detect ACS, but they were required to use at least slice CT technology for patient assessment.
Stay up-to-date with breaking news, conference slides, and topical videos covering the spectrum of CVD. Join our newsletter! Register today! News Daily News. Created with Sketch. July 26, Table 1. Effectiveness of CTA vs. Daily News. Screening of acute chest pain patients in the emergency department with coronary computed tomographic angiography CTA safely hastens diagnosis and shortens hospital stay, according to a randomized study published in the July 26, , issue of the New England Journal.
Similar characteristics have been demonstrated to represent high-risk plaque on histology necrotic lipid rich core, thin-cap fibroatheroma, positive remodeling, spotty calcium 12 , 13 and intravascular imaging positive remodeling, larger plaque volume, spotty calcium 14 , Furthermore, initial evidence from CTA studies suggests that these features were associated with an increased risk for future cardiovascular events in patients with stable chest pain syndromes 16 - 18 However, there are limited data on the potential use of high-risk plaque on CTA in patients with acute chest pain 19 , This study's primary aim was to determine whether high-risk plaque features, as detected by CTA in the ED, may improve diagnostic certainty of ACS independent and incremental to the presence of significant CAD and clinical risk assessment in patients with acute chest pain but without objective evidence of myocardial ischemia or myocardial infarction MI.
A detailed description of the patient population was reported 2. Between April and January , 1, patients with cardiovascular risk factors presenting to the ED of 9 U.
The local institutional review boards approved the study. The images were transferred to the core lab. Each reader analyzed one-third of randomly assigned CTA datasets. Further, 30 randomly selected CTA datasets were analyzed by all 3 readers to determine interobserver agreement. For each coronary segment, the reader determined whether the image quality was sufficient to evaluate for the presence of stenosis and coronary plaque with confidence.
Coronary segments that were assessed as non-diagnostic in image quality were treated as non-informative for the purpose of the analysis. Each evaluable coronary segment was assessed for the presence of stenosis. For each evaluable coronary segment, we noted the presence of plaque. Non-calcified coronary plaque was defined as any discernible structure that could be assigned to the coronary artery wall, had a CT number below the contrast-enhanced coronary lumen but above the surrounding connective tissue, and could be identified in at least 2 independent planes In each coronary segment with plaque, we performed further qualitative evaluation for the presence of high-risk plaque features, which were defined as positive remodeling, low CT number of plaque, napkin-ring sign, and spotty calcium Central Illustration.
Positive remodeling was assessed visually in multi-planar reformatted images reconstructed in long axis and short axis view of the vessel.
Additional manual measurements of outer vessel diameter were performed at readers' discretion, and threshold of 1. The napkin ring sign was defined as a ring-like peripheral higher attenuation of the non-calcified portion of the coronary plaque 20 , 23 - The patient was classified as having high-risk plaque features, if at least 1 high-risk plaque feature was present.
The primary outcome of the study was an ACS event during the index hospitalization. An independent clinical-events committee predefined and adjudicated the endpoint.
We excluded ACS myocardial infarction during the index hospitalization in a patient with an anomalous right coronary artery from the main pulmonary artery, but with no evidence of coronary plaque or stenosis, who underwent the re-implantation of the right coronary artery during the index hospitalization.
All statistical analyses were performed using Stata Comparisons between groups were performed with the use of an independent sample t-test for continuous variables, Fisher's exact test for categorical variables, and the Wilcoxon rank-sum test for ordinal variables. To determine whether high-risk plaque is incremental to presence of significant CAD and clinical risk assessment, we compared areas under the receiver operating characteristics curve AUC using the DeLong algorithm One patient was excluded from further analysis due to non-diagnostic image quality in all coronary segments.
Overall, patients who underwent CTA with diagnostic image quality formed the study population mean age The prevalence of ACS was 7. Overall of 6, 2. CAD, defined as the presence of any plaque, was detected in Among patients with coronary plaque, calcified plaques were present in At least 1 high-risk plaque feature was present in of The prevalence of the individual high-risk plaque features in patients with significant CAD was as follows: spotty calcium in 40 At least 1, 2, and 3 high-risk plaque features were present in The prevalence of the individual high-risk plaque features in patients with non-obstructive CAD was as follows: spotty calcium in Patients with at least 1 high-risk plaque feature were 32 times more likely to have an ACS during the index hospitalization.
All individual high-risk plaque features were associated with ACS. Probability of having acute coronary syndrome during the index hospitalization according to coronary computed tomography characteristics.
Central Illustration: Significant stenosis and high-risk coronary plaque features and their association with probability of having acute coronary syndrome during the index hospitalization. Non-calcified plaque with positive remodeling in the distal right coronary artery arrowhead. Positive remodeling — The two dotted red lines image insert demonstrate the vessel diameters at the proximal and distal reference both 1.
Napkin ring sign — Napkin ring sign plaque in the mid left anterior descending coronary artery. Schematic cross-sectional view of the napkin ring sign. The red line demonstrates the central low HU area of the plaque adjacent to the lumen yellow ellipse surrounded by a peripheral rim of the higher CT attenuation red arrows.
In the logistic regression analysis Table 3 , the presence of high-risk plaque odds ratio 8. We observed that adding the presence of high-risk plaque to the model further improved the prediction of ACS model 3: AUC 0.
We demonstrated that high-risk coronary plaque as detected on CTA in patients presenting to the ED with acute chest pain was associated with ACS independently and incrementally to the presence of significant CAD and clinical risk assessment. Our results suggested that CTA based assessment of high-risk plaque improved diagnosis of ACS in patients with acute chest pain who otherwise have no electrocardiographic or enzymatic evidence of ischemia or infarction. Our understanding of morphologic features of high-risk plaque stems primarily from the histology studies of patients who died from sudden cardiac death.
The histologic features of the culprit plaques included large necrotic core, higher macrophage count, positive remodeling, speckled calcium, and thin fibrous cap 12 , Similar morphologic features positive remodeling, larger plaque area, spotty calcium, and large necrotic core were observed with intravascular imaging in culprit lesions of ACS 14 , We did not perform quantitative analysis of plaques, which is necessary for the calculation of plaque burden.
However, there is a correlation between positive remodeling and large plaque burden. Finally, the spatial resolution of CTA does not permit the detection of thin-cap fibroatheroma.
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