Cardiology/original researchThe Diagnostic Accuracy of 64-Slice Computed Tomography Coronary Angiography Compared With Stress Nuclear Imaging in Emergency Department Low-Risk Chest Pain Patients
Introduction
Each year, roughly 6 million patients are evaluated for chest pain in emergency departments (EDs).1 Accurate and efficient screening for patients with an acute coronary syndrome is essential. Historically, 2% to 10% of patients with an acute coronary syndrome are inappropriately sent home from the ED.2 Missed diagnosis of acute myocardial infarction is associated with significant morbidity, and it is the leading contributor to malpractice claims paid by emergency physicians.3 Because of this, many patients are admitted for further testing, with the majority found to not have an acute coronary syndrome. It is estimated that the cost of these negative evaluations is $10 to $13 billion per year. To address these issues, EDs have developed chest pain units and diagnostic protocols. These protocols commonly include serial cardiac serum marker evaluations and ECGs, followed by stress testing, with or without radionuclide imaging.4, 5
Rapid advances in multidetector computed tomographic (CT) technology have allowed noninvasive coronary artery imaging. Studies comparing 64-slice multidetector CT with invasive coronary angiography have shown that multidetector CT performs well in the detection of significant coronary stenosis, with sensitivities ranging from 82% to 95% and specificities of 82% to 98%.6, 7, 8, 9 The presence of coronary calcification in patients with acute chest pain has also been shown to be predictive of future cardiac events.10 However, there are no studies that compare the ability of multidetector CT to detect an acute coronary syndrome with traditional stress nuclear imaging in low-risk chest pain patients.
Our study objective was to compare the diagnostic accuracy of multidetector CT with traditional stress nuclear imaging for the detection of an acute coronary syndrome in ED low-risk chest pain patients.
Section snippets
Materials and methods
This was a prospective institutional review board–approved study comparing the diagnostic accuracy of multidetector CT and radionuclide rest/stress imaging in a convenience sample of low-risk chest pain patients. Study patients received a multidetector CT and a radionuclide stress test, thus allowing each patient to serve as his or her own control.
Results
Patient enrollment occurred during 7 months, from September 2004 to March 2005. Throughout the study period, there were 68,367 ED visits, of which 2,182 patients (age 58±16 years; 46% men) were sent to the ED observation unit for the chest pain diagnostic protocol; 13% were subsequently admitted.
Limitations
This study has several important limitations to consider. Using the results of the multidetector CT and stress nuclear imaging to determine who would undergo angiography or who would have a follow-up appointment may have introduced an incorporation bias. Because we did not feel it ethical to withhold test results from those treating patients, knowledge of multidetector CT or stress nuclear imaging results may have also introduced a referral bias. Because cardiac catheterization did not occur in
Discussion
This study shows that multidetector CT has accuracy that is comparable to that of stress nuclear imaging for the detection of an acute coronary syndrome in ED low-risk chest pain patients. As such, it appears to be a reasonable alternative to stress nuclear imaging in a “low-risk” ED chest pain population after negative serial ECG and cardiac marker results.
During the last 2 decades, there has been a progressive evolution in the management of ED chest pain patients at risk for an acute coronary
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Cited by (229)
High-Risk Chief Complaints I: Chest Pain—The Big Three (an Update)
2020, Emergency Medicine Clinics of North AmericaCitation Excerpt :CTCA allows for the noninvasive evaluation of the extent of calcium deposits and degree of stenosis in the coronary arteries, and interest in its use stemmed from data demonstrating a high level of diagnostic accuracy compared with invasive coronary angiography.117 Studies evaluating its use in ED patients with chest pain consistently reported a negative predictive value for the presence of CAD between 97% and 100%118–122 and an accuracy comparable to stress testing in the identification of CAD.123,124 Moreover, 2 large randomized trials of 1000125 and 1370126 patients comparing use of CTCA to standard care in patients with low- to intermediate-risk chest pain both described this excellent negative predictive value as well as improved time to discharge and frequency of discharge from the ED.
Head-to-head comparison of the diagnostic performance of coronary computed tomography angiography and dobutamine-stress echocardiography in the evaluation of acute chest pain with normal ECG findings and negative troponin tests: A prospective multicenter study
2017, International Journal of CardiologyDifference of coronary stenosis severity between systolic and diastolic phases in quantitative CT angiography
2017, Journal of Cardiovascular Computed Tomography2015 ACR/ACC/AHA/AATS/ACEP/ASNC/NASCI/SAEM/SCCT/SCMR/SCPC/SNMMI/STR/STS Appropriate Utilization of Cardiovascular Imaging in Emergency Department Patients With Chest Pain: A Joint Document of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Appropriate Use Criteria Task Force
2016, Journal of the American College of Cardiology2015 ACR/ACC/AHA/AATS/ACEP/ASNC/NASCI/SAEM/SCCT/SCMR/SCPC/SNMMI/STR/STS Appropriate Utilization of Cardiovascular Imaging in Emergency Department Patients with Chest Pain :A Joint Document of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Appropriate Use Criteria Task Force
2016, Journal of the American College of RadiologyCalcium Scoring and Cardiac Computed Tomography
2016, Heart Failure Clinics
Supervising editors: Judd E. Hollander, MD; Michael L. Callaham, MD
Author contributions: MJG, MAR, GLR, JAG, and BO conceived and designed the study. MJG, GLR, JAG, and WWO obtained internal funding to support the study. All were engaged in patient enrollment. MJG, MAR, GLR, and BO were involved in data analysis and article preparation. All authors were involved in final article revisions. MR takes responsibility for the paper as a whole.
Funding and support: Sponsored in part by a grant from the Minestrelli Advanced Cardiac Research Imaging Center, Royal Oak, MI.
Reprints not available from the authors.