Prognostic Value of CT Angiography for Major Adverse Cardiac Events in Patients With Acute Chest Pain From the Emergency Department 2-Year Outcomes of the ROMICAT Trial

OBJECTIVES: The aim of this study was to determine the 2-year prognostic value of cardiac computed tomography (CT) for predicting major adverse cardiac events (MACE) in patients presenting to the emergency department (ED) with acute chest pain. CT has high potential for early triage of acute chest pain patients. However, there is a paucity of data regarding the prognostic value of CT in this ED cohort.

METHODS: We followed 368 patients from the ROMICAT (Rule Out Myocardial Infarction Using Computer Assisted Tomography) trial (age 53 ± 12 years; 61% male) who presented to the ED with acute chest pain, negative initial troponin, and a nonischemic electrocardiogram for 2 years. Contrast-enhanced 64-slice CT was obtained during index hospitalization, and caregivers and patients remained blinded to the results. CT was assessed for the presence of plaque, stenosis (>50% luminal narrowing), and left ventricular regional wall motion abnormalities (RWMA). The primary endpoint was MACE, defined as composite cardiac death, nonfatal myocardial infarction, or coronary revascularization.

RESULTS: Follow-up was completed in 333 patients (90.5%) with a median follow-up period of 23 months. At the end of the follow-up period, 25 patients (6.8%) experienced 35 MACE (no cardiac deaths, 12 myocardial infarctions, and 23 revascularizations). Cumulative probability of 2-year MACE increased across CT strata for coronary artery disease (CAD) (no CAD 0%; nonobstructive CAD 4.6%; obstructive CAD 30.3%; log-rank p < 0.0001) and across combined CT strata for CAD and RWMA (no stenosis or RWMA 0.9%; 1 feature-either RWMA [15.0%] or stenosis [10.1%], both stenosis and RWMA 62.4%; log-rank p < 0.0001). The c statistic for predicting MACE was 0.61 for clinical Thrombolysis In Myocardial Infarction risk score and improved to 0.84 by adding CT CAD data and improved further to 0.91 by adding RWMA (both p < 0.0001).

CONCLUSIONS: CT coronary and functional features predict MACE and have incremental prognostic value beyond clinical risk score in ED patients with acute chest pain. The absence of CAD on CT provides a 2-year MACE-free warranty period, whereas coronary stenosis with RWMA is associated with the highest risk of MACE. Byron Maxwell Jersey

PMID: 21565735

Posted in * Journal Club Selections, Computed Tomography and tagged , , , , , , , .

2 Comments

  1. The study highlights a welcome development in the management of acute chest pain syndrome in the ED. The study performed coronary CTA in a series of patients presenting with acute chest pain to the ED, and were judged to be at low clinical risk. The article outlines the prognostic utility of CT scan in these patients with suspected cardiac cause of chest pain.

    One of the strengths of this study is that it could lead to a shorter hospital stay for low risk patients and result in cost cutting measures.

    The authors used regional wall motion abnormality (RWMA) as an added prognosticator not overall ejection fraction. RWMA may be a false positive result from artifact during image acquisition. Based on the cardiac ischemic cascade, the occurrence of RWMA and systolic dysfunction will precede the development of symptoms or ECG changes. RWMA could thus be beneficial in patients with cardiac pain at the time of image acquisition. While the presence of RWMA points toward acute ischemia, EF has been widely studied and prognostically validated.

    The other issue arises from the absence of a metabolic or functional portion of CTA test. What will happen to the patients with persistent chest pain despite a negative CTA? With current ED procedures this patients will likely still undergo a perfusion scan or stress echocardiography leading to more tests, costs and radiation exposure (as in the case of nuclear studies).

    Overall, the ROMICAT study is an improtant step toward the rapid triage of patients in the ED presenting with chest pain syndrome.

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