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CLINICAL RESEARCH: CLINICAL TRIAL

Coronary Computed Tomography Angiography for Early Triage of Patients With Acute Chest Pain

The ROMICAT (Rule Out Myocardial Infarction using Computer Assisted Tomography) Trial

Udo Hoffmann, MD, MPH^_*,,_*, Fabian Bamberg, MD, MPH^_*,, Claudia U. Chae, MD, MPH, John H. Nichols, BA^_*, Ian S. Rogers, MD, MBA^_*, Sujith K. Seneviratne, MBBS^_*, Quynh A. Truong, MD^_*, Ricardo C. Cury, MD^_*,, Suhny Abbara, MD^_*,, Michael D. Shapiro, DO^_*, Jamaluddin Moloo, MD^_*, Javed Butler, MD, MPH^_*, Maros Ferencik, MD, PhD^_*, Hang Lee, PhD, Ik-Kyung Jang, MD, PhD, Blair A. Parry, BA^||, David F. Brown, MD^||, James E. Udelson, MD^¶, Stephan Achenbach, MD^#, Thomas J. Brady, MD^_*, and John T. Nagurney, MD, MPH^||

^_* Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
Division of Cardiology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
Biostatistics Center, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
^|| Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
^¶ Cardiology Division, Tufts Medical Center and Tufts University School of Medicine, Boston, Massachusetts
^# Department of Cardiology, University of Erlangen, Erlangen, Germany

Manuscript received October 31, 2008; revised manuscript received December 19, 2008, accepted January 12, 2009.

^_* Reprint requests and correspondence: Dr. Udo Hoffmann, Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, 165 Charles River Plaza, Suite 400, Boston, Massachusetts 02114 (Email: uhoffmann{at}partners.org).

Objectives: This study was designed to determine the usefulness of coronary computed tomography angiography (CTA) in patients with acute chest pain.

Background: Triage of chest pain patients in the emergency department remains challenging.

Methods: We used an observational cohort study in chest pain patients with normal initial troponin and nonischemic electrocardiogram. A 64-slice coronary CTA was performed before admission to detect coronary plaque and stenosis (>50% luminal narrowing). Results were not disclosed. End points were acute coronary syndrome (ACS) during index hospitalization and major adverse cardiac events during 6-month follow-up.

Results: Among 368 patients (mean age 53 ± 12 years, 61% men), 31 had ACS (8%). By coronary CTA, 50% of these patients were free of coronary artery disease (CAD), 31% had nonobstructive disease, and 19% had inconclusive or positive computed tomography for significant stenosis. Sensitivity and negative predictive value for ACS were 100% (n = 183 of 368; 95% confidence interval [CI]: 98% to 100%) and 100% (95% CI: 89% to 100%), respectively, with the absence of CAD and 77% (95% CI: 59% to 90%) and 98% (n = 300 of 368, 95% CI: 95% to 99%), respectively, with significant stenosis by coronary CTA. Specificity of presence of plaque and stenosis for ACS were 54% (95% CI: 49% to 60%) and 87% (95% CI: 83% to 90%), respectively. Only 1 ACS occurred in the absence of calcified plaque. Both the extent of coronary plaque and presence of stenosis predicted ACS independently and incrementally to Thrombolysis In Myocardial Infarction risk score (area under curve: 0.88, 0.82, vs. 0.63, respectively; all p < 0.0001).

Conclusions: Fifty percent of patients with acute chest pain and low to intermediate likelihood of ACS were free of CAD by computed tomography and had no ACS. Given the large number of such patients, early coronary CTA may significantly improve patient management in the emergency department.

Key Words: cardiac CT • emergency department • acute chest pain

Abbreviations and Acronyms   ACS = acute coronary syndrome   AUC = area under the receiver-operating characteristics curve   CAD = coronary artery disease   CI = confidence interval   CT = computed tomography   CTA = computed tomography angiography   ECG = electrocardiogram   ED = emergency department   MACE = major adverse cardiac event(s)   MI = myocardial infarction   NPV = negative predictive value   OR = odds ratio   PPV = positive predictive value   SPECT = single-positron emission computed tomography   TIMI = Thrombolysis In Myocardial Infarction   UAP = unstable angina pectoris

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