Fabian Bamberg

Coronary Computed Tomography Angiography for Early Triage of Patients With Acute Chest Pain The ROMICAT (Rule Out Myocardial Infarction using Computer Assisted Tomography) Trial

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.

Cardiac Magnetic Resonance With T2-Weighted Imaging Improves Detection of Patients With Acute Coronary Syndrome in the Emergency Department

Background— Cardiac magnetic resonance (CMR) imaging permits early triage of patients presenting to the emergency department with acute chest pain but has been limited by the inability to differentiate new from old myocardial infarction. Our objective was to evaluate a CMR protocol that includes T2-weighted imaging and assessment of left ventricular wall thickness in detecting patients with acute coronary syndrome in the emergency department. Methods and Results— In this prospective cohort observational study, we enrolled patients presenting to the emergency department with acute chest pain, negative cardiac biomarkers, and no ECG changes indicative of acute ischemia. The CMR protocol consisted of T2-weighted imaging, first-pass perfusion, cine function, delayed-enhancement magnetic resonance imaging, and assessment of left ventricular wall thickness. The clinical outcome (acute coronary syndrome) was defined by review of clinical charts by a consensus panel that used American Heart Association/American College of Cardiology guidelines. Among 62 patients, 13 developed acute coronary syndrome during the index hospitalization. The mean CMR time was 32±8 minutes. The new CMR protocol (with the addition of T2-weighted and left ventricular wall thickness) increased the specificity, positive predictive value, and overall accuracy from 84% to 96%, 55% to 85%, and 84% to 93%, respectively, compared with the conventional CMR protocol (cine, perfusion, and delayed-enhancement magnetic resonance imaging). Moreover, in a logistic regression analysis that contained information on clinical risk assessment (c-statistic=0.695) and traditional cardiac risk factors (c-statistic=0.771), the new CMR protocol significantly improved the c-statistic to 0.958 (P<0.0001). Conclusions— The present study indicates that a new CMR protocol improves the detection of patients with acute coronary syndrome in the emergency department and adds significant value over clinical assessment and traditional cardiac risk factors.

Meta-Analysis and Systematic Review of the Long-Term Predictive Value of Assessment of Coronary Atherosclerosis by Contrast-Enhanced Coronary Computed Tomography Angiography

OBJECTIVES We conducted a systematic review and meta-analysis to determine the predictive value of findings of coronary computed tomography angiography for incident cardiovascular events. BACKGROUND Initial studies indicate a prognostic value of the technique; however, the level of evidence as well as exact independent risk estimates remain unclear. METHODS We searched PubMed, EMBASE, and the Cochrane Library through January 2010 for studies that followed up ≥ 100 subjects for ≥ 1 year and reported at ≥ 1 hazard ratio (HR) of interest. Risk estimates for the presence of significant coronary stenosis (primary endpoint; ≥ 50% diameter stenosis), left main coronary artery stenosis, each coronary stenosis, 3-vessel disease, any plaque, per coronary segment containing plaque, and noncalcified plaque were derived in random effect regression analysis, and causes of heterogeneity were determined in meta-regression analysis. RESULTS We identified 11 eligible articles including 7,335 participants (age 59.1 ± 2.6 years, 62.8% male) with suspected coronary artery disease. The presence of ≥ 1 significant coronary stenosis (9 studies, 3,670 participants, and 252 outcome events [6.8%] with 62% revascularizations) was associated with an annualized event rate of 11.9% (6.4% in studies excluding revascularization). The corresponding HR was 10.74 (98% confidence interval [CI]: 6.37 to 18.11) and 6.15 (95% CI: 3.22 to 11.74) in studies excluding revascularization. Adjustment for coronary calcification did not attenuate the prognostic significance (p = 0.79). The estimated HRs for left main stenosis, presence of plaque, and each coronary segment containing plaque were 6.64 (95% CI: 2.6 to 17.3), 4.51 (95% CI: 2.2 to 9.3), and 1.23 (95% CI: 1.17 to 1.29), respectively. CONCLUSIONS Presence and extent of coronary artery disease on coronary computed tomography angiography are strong, independent predictors of cardiovascular events despite heterogeneity in endpoints, categorization of computed tomography findings, and study population.

Noninvasive 24-h ambulatory blood pressure and cardiovascular disease: a systematic review and meta-analysis

Objective We systematically assessed the evidence regarding the association between noninvasive 24-h systolic blood pressure and incident cardiovascular events. Methods We searched PubMed, EMBASE, and the Cochrane Library through April 2007. Studies that prospectively followed at least 100 individuals for at least 1 year, and that reported at least one effect estimate of interest were included. Two independent investigators abstracted information on study design, subject characteristics, blood pressure measurements, outcome assessment, effect estimates, and adjustment for potential confounders. Results We identified 20 eligible articles based on 15 independent cohort studies. The association between 24-h systolic blood pressure and a combined cardiovascular endpoint was assessed in nine cohort studies, including 9299 participants who were followed up to 11.1 years and had 881 outcome events. The summary hazard ratio (95% confidence interval) per 10-mmHg increase of 24-h systolic blood pressure was 1.27 (1.18–1.38) (P < 0.001). Further adjustment for office blood pressure in four studies with 4975 participants and 499 outcome events provided a similar summary estimate [hazard ratio (95% confidence interval) per 10-mmHg increase of 24-systolic blood pressure 1.21 (1.10–1.33) (P < 0.001)]. Office blood pressure was usually assessed on a single occasion. We found no significant variability according to age, sex, population origin, baseline office blood pressure, follow-up time, diabetes, or study quality. There was a consistent association between 24-h systolic blood pressure and stroke, cardiovascular mortality, total mortality, and cardiac events with hazard ratio (95% confidence interval) per 10 mmHg increase of 24-h systolic blood pressure of 1.33 (1.22–1.44), 1.19 (1.13–1.26), 1.12 (1.07–1.17), and 1.17 (1.09–1.25), respectively. Conclusion 24-h systolic blood pressure is a strong predictor of cardiovascular events, providing prognostic information independent of conventional office blood pressure.

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. BACKGROUND 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.

Cost-Effectiveness of Coronary MDCT in the Triage of Patients with Acute Chest Pain

OBJECTIVE Patients at low risk for acute coronary syndrome (ACS) who present to the emergency department complaining of acute chest pain place a substantial economic burden on the U.S. health care system. Noninvasive 64-MDCT coronary angiography may facilitate their triage, and we evaluated its cost-effectiveness. MATERIALS AND METHODS A microsimulation model was developed to compare costs and health effects of performing CT coronary angiography and either discharging, stress testing, or referring emergency department patients for invasive coronary angiography, depending on their severity of atherosclerosis, compared with a standard-of-care (SOC) algorithm that based management on biomarkers and stress tests alone. RESULTS Using CT coronary angiography to triage 55-year-old men with acute chest pain increased emergency department and hospital costs by

Prediction model to estimate presence of coronary artery disease: Retrospective pooled analysis of existing cohorts

110 and raised total health care costs by

Emphysema diagnosis using X-ray dark-field imaging at a laser-driven compact synchrotron light source

200. In 55-year-old women, the technology was cost-saving; emergency department and hospital costs decreased by

Prevalence of nonstenosing, complicated atherosclerotic plaques in cryptogenic stroke

410, and total health care costs decreased by

Association of Leukocyte and Neutrophil Counts With Infarct Size, Left Ventricular Function and Outcomes After Percutaneous Coronary Intervention for ST-Elevation Myocardial Infarction

380. Compared with the SOC, CT coronary angiography-based triage extended life expectancy by 10 days in men and by 6 days in women. This translated into corresponding improvements of 0.03 quality-adjusted life years (QALYs) and 0.01 QALYs, respectively. The incremental cost-effectiveness ratio for CT coronary angiography was