Abstract
PurposeThe purpose of this study was to assess the diagnostic accuracy and one year prognosis of whole chest, “multiple rule out” CT for coronary artery disease (CAD) in Emergency Department patients.Methods and FindingsOne hundred and two Emergency Department patients at low to intermediate risk of acute coronary syndrome (ACS), pulmonary embolism and/or acute aortic syndrome underwent a research 64 channel ECG-gated, whole chest CT and a standard of care evaluation. Patients were classified with obstructive CAD with either a coronary CT stenosis greater than 50% or a non-evaluable coronary segment. SOC and 3 month follow up data were used to determine an adjudicated clinical diagnosis. The diagnostic ability of obstructive CAD on CT to identify clinical diagnoses was determined. Patients were followed up for 1 year for cardiac events. Seven (7%) patients were diagnosed with ACS. CT sensitivity to detect obstructive CAD in ACS patients was 100% (95% CI 65%, 100%), negative predictive value 100% (96%, 100%), specificity 88% (80%, 94%), and positive predictive value 39% (17%, 64%). Pulmonary embolism and acute aortic syndrome were not identified in any patients. No cardiac events occurred in patients without obstructive CAD over 1 year.ConclusionsWhole chest CT has high sensitivity and negative predictive value for ACS with excellent one year prognosis in patients without obstructive CAD on CT. The frequency of pulmonary embolism or acute aortic syndrome and the higher radiation dose suggest whole chest CT should be limited to select patients.ClinicalTrials.org #: NCT00855231
Highlights
Patients who present to the Emergency Department (ED) with possible acute coronary syndrome (ACS) commonly have symptoms that suggest a larger differential diagnosis than ACS alone
Five patients had myocardial infarction by elevated troponin I during standard of care (SOC) hospitalization and two patients were diagnosed with unstable angina
Two patients that were sent for invasive coronary angiography based on SOC clinical evaluation showed no obstructive coronary artery disease (CAD) on computed tomography (CT) or invasive angiography
Summary
The considerable overlap of symptoms for multiple potential life threatening disease, including pulmonary embolism (PE) and acute aortic syndrome (AAS), makes ED evaluation challenging and may result in missed diagnoses in up to 10% of these patients [1,2,3]. Whole chest computed tomography (CT) may be useful in these patients using a ‘‘Triple-’’ or ‘‘Multiple-Rule-Out’’ technique to evaluate coronary arteries, aorta, pulmonary vasculature, and intrathoracic structures in a single study. Use of whole chest CT in ED patients is controversial due to potential compromise of coronary artery image quality, the higher radiation dose, and the higher prevalence of incidental CT findings [14,15]. Our study explored the diagnostic accuracy, radiation dose, extracardiac findings, and one year prognosis of whole chest CT in a cohort of low to intermediate risk ED patients
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