Suspicion Of Acute Coronary Syndrome Research Articles

Avaliação da qualidade do atendimento ao paciente com síndrome coronariana aguda no serviço de emergência

Estudo com objetivo de avaliar indicadores de qualidade no atendimento aos pacientes com suspeita de síndrome coronariana aguda (SCA) e associá-los a alta, óbito e tempo de internação hospitalar. Pesquisa transversal, analítica de 84 prontuários de pacientes com suspeita de SCA no Serviço de Emergência. Foi estudada a associação entre os fatores de risco e indicadores de qualidade no atendimento à SCA com: tempo de internação, óbito, recorrência de eventos isquêmicos e revascularização do miocárdio por meio da correlação de Spearman. O tempo de internação foi significativamente menor para pacientes com infarto sem supradesnivelamento de ST que tiveram menor intervalo entre admissão e tratamento. Para pacientes com infarto com supradesnivelamento de ST, o tempo de internação foi significativamente menor quando o intervalo entre classificação de risco e tratamento foi menor. Não houve associação dos indicadores de qualidade com recorrência de eventos isquêmicos, revascularização do miocárdio, tempo de internação e óbito.

Abstract 279: Troponin Testing in the Emergency Setting: Analysis of Appropriateness

Background: Troponin levels are routinely tested and trended in emergency departments even in the absence of clinical suspicion for Acute Coronary Syndrome. This can result in increased utilization of resources. We examined the rates at which troponin assays were drawn on admission to the medical service of our hospital and the appropriate use fo this assay. Methods: Consecutive patients admitted to the medical wards of our hospital over a one month period for which a Troponin level was obtained within 8 hours of arrival were prospectively identified. Baseline demographic and clinic characteristics and information regarding the admitting diagnosis were obtained through a detailed chart review. Cardiology testing or consults that were obtained soley for evaluation of an abnormal troponin were recorded. We defined an inappropriate troponin test (IT) as one that was drawn in the absence of a clear reason including, ischemic like symptoms (chest pain, epigastric pain, upper back pain, jaw pain or left shoulder/arm pain), unexplained shortness of breath, new ECG changes, syncope, arrhythmia or CHF. Results: Among 142 patients identified, 47 (33%) had IT. These patients were 61.9 ± 19.3 years of age (range 19-102 years), and 18 (38.3%) were female. Admitting diagnoses for those patients who had IT included the following: Altered mental status 8 (17%); Sepsis/Infection 8 (17%); Weakness 6 (12.8%); Other GI symptoms 5 (10.6%); GI Bleeding 2 (4.3%); Other miscellanous diagnosis 18 (38.3%). Table 1 depicts the characteristics of these patients. Conclusion: Significant number of patients admitted with non-cardiac diagnoses have Troponin assays drawn for unapparent reasons; This IT assay rarely results in the identification of a new cardiac diagnosis. In the long term, these IT can result in a significant and unnecessary increased utilization of hospital resources.

Estimation of age- and comorbidities-adjusted percentiles of high-sensitivity cardiac troponin T levels in the elderly.

Cardiac troponin level measured by high-sensitivity assays (hs-cTn) in the elderly is frequently found higher than the 99th percentile upper reference limit, making the diagnosis of acute coronary syndromes (ACS) difficult. This study aimed at: 1) identifying determinants of hs-cTnT levels in an unselected population of elderly subjects; and 2) assessing the prognosis value of increased hs-cTnT in elderly people free of ACS. Hs-cTnT was measured in 591 individuals aged over 65 years without suspicion of ACS. Comorbidities were assessed using the Cumulative Illness Rating Scale for Geriatrics (CIRS-G). C-reactive protein, α1-acid glycoprotein, albumin and creatinine were measured. Factors influencing hs-cTnT levels were assessed through linear regression and quantile regression was used to model percentiles of hs-cTnT. Risk of mortality was assessed through Cox regression. Age, gender, cardiac CIRS-G, estimated glomerular filtration rate (p<0.001 for all), albumin (p<0.028) and α1-acid glycoprotein (p=0.002) were independent predictors of hs-cTnT. After exclusion of outliers, the median was 15 ng/L and 99th percentile was 64 ng/L. After controlling for comorbidities, the 99th percentile increased from 24 ng/L at age 65 to 53 ng/L at age 90 in females and from 33 ng/L to 75 ng/L in males. In multivariate analysis, hs-cTnT level was significantly related to mortality. Hs-cTnT level is associated with inflammation and renal function in the elderly. Independently of comorbidities, hs-cTnT concentration increases exponentially with age after 65 years. Decision limits adapted to age and sex may be useful to patient management.

Outcomes of patients hospitalized for suspected acute coronary syndrome, in whom the diagnosis was not confirmed: Results from the CZECH-1 and CZECH-2 registries

BackgroundSuspicion of acute coronary syndrome (ACS) is one of the most common reasons for hospital admission. However, ACS is not confirmed in a high proportion of these patients during hospitalization. Very few details exist about these patients. AimTo evaluate the clinical characteristics and outcomes of hospitalized patients with a suspicion for ACS that has not been confirmed and compare these results with patients with confirmed ACS. Methods and resultsData were used from the CZECH-1 and CZECH-2 registries, collected in November 2005 and October–November 2012. Both registries contain data from all consecutive patients who have been hospitalized with an initial diagnosis of ACS. ACS was not confirmed during hospitalization in 578 of 1921 patients (30.1%) in the CZECH-1 registry and in 372 of 1221 (30.5%) in the CZECH-2 registry. In both registries, higher proportions of females (52 vs. 36%; p<0.001 and 46 vs. 33%; p<0.01, respectively) were observed between patients with unconfirmed ACS compared to those with confirmed ACS. A history of myocardial infarction was known in 25% of the patients with unconfirmed ACS in both registries. On admission, atrial fibrillation or other non-sinus rhythm on ECG was present in 17% of patients with unconfirmed ACS, bundle branch block in 18%, ST depression in 8%, and ST elevation in 3.6%. Coronary angiography was performed on 36% of these patients in CZECH-1 and 27% of patients in CZECH-2 (p<0.01). In-hospital mortality of the ACS unconfirmed patients was 1.2% in the CZECH-1 registry and 2.1% in the CZECH-2 registry (p=NS). 30-day and 1-year mortality in patients with unconfirmed ACS in the CZECH-2 registry were significantly lower compared to patients with confirmed ACS (3.5 vs. 6.6%; p<0.05 and 6.5 vs. 13%; p<0.05, respectively). Musculoskeletal pain and acute heart failure were the most common discharge diagnosis in patients with unconfirmed ACS. ConclusionHospitalized patients in whom the suspicion of ACS had not been confirmed were more often female and a high proportion had abnormal ECG on admission. In-hospital mortality was very low, and the 1-year mortality was significantly lower compared to patients with confirmed ACS.

Sequential analysis of myeloperoxidase for prediction of adverse events after suspected acute coronary ischemia.

Myeloperoxidase (MPO) plasma values predict major adverse cardiac events (MACE) in cases of acute coronary syndrome. The effect of serial testing in patients who are suspected for acute coronary ischemia is unclear. We hypothesize that sequential MPO measurement may improve prediction of MACE in patients with suspected acute coronary ischemia. The present prospective observational study examined the prognostic significance of MPO in 917 patients with suspicion of acute coronary syndrome. Blood samples were taken at cardiac catheter laboratory admission and the day after coronary angiography. We recorded patients' mortality, the occurrence of cardiac ischemia, and repeated percutaneous coronary intervention through the next 6 months. Mortality among patients with increased MPO plasma levels the day after coronary angiography was increased significantly (P < 0.01). Patients with MPO values above 306.3 pmol/L had a significantly higher incidence of 6-month MACE (P < 0.0001) than patients with lower plasma values. Cox proportional hazards multivariate regression analyses revealed that MPO was an independent marker for MACE after suspected acute coronary ischemia (P = 0.048). However, MPO plasma levels at cardiac catheter laboratory admission showed no prognostic significance. In patients with suspected myocardial infarction, MPO levels above 306.3 pmol/L measured 24 hours after onset of symptoms were independent predictors of 6-month mortality and MACE.

What decides the suspicion of acute coronary syndrome in acute chest pain patients?

BackgroundPhysicians assessing chest pain patients in the emergency department (ED) base the likelihood of acute coronary syndrome (ACS) mainly on ECG, symptom history and blood markers of myocardial injury. Among these, the ECG has been stated to be the most important diagnostic tool. We aimed to analyze the relative contributions of these three diagnostic modalities to the ED physicians’ evaluation of ACS likelihood in clinical practice.Methods1151 consecutive ED chest pain patients were prospectively included. The ED physician’s subjective assessment of the patient’s likelihood of ACS (obvious ACS, strong, vague or no suspicion of ACS), the symptoms and the ECG were recorded on a special form. The ED TnT value was retrieved from the medical records. Frequency tables and logistic regression models were used to evaluate the contributions of the diagnostic tests to the level of ACS suspicion.ResultsSymptoms determined whether the physician had any suspicion of ACS (odds ratio, OR 526 for symptoms typical compared to not suspicious of ACS) since neither ECG nor TnT contributed significantly (ORs not significantly different from 1) to this assessment. ACS was suspected in only one in ten patients with symptoms not suspicious of ACS. Symptoms were also more important (OR 620 for typical symptoms) than ECG (OR 31 for ischemic ECG) and TnT (OR 3.4 for a positive TnT) for the assessment of obvious ACS/strong suspicion versus vague/no suspicion. Of the patients with ST-elevation on ECG, 71% were considered to have an obvious ACS, as opposed to only 6% of those with symptoms typical of ACS and 10% of those with a positive TnT.ConclusionThe ED physicians used symptoms as the most important assessment tool and applied primarily the symptoms to determine the level of ACS suspicion and to rule out ACS. The ECG was primarily used to rule in ACS. The TnT level played a minor role for the assessment of ACS likelihood. Further studies regarding ACS prediction based on symptoms may help improve decision-making in ED patients with possible ACS.

Foreign body mimicking acute coronary syndrome

The article presents a case study of a 37-year-old male who was admitted to the Acute Cardiology Unit of our hospital with suspicion of acute coronary syndrome. By invasive imaging examination, acute coronary syndrome was ruled out, but as a secondary finding a foreign body was found in the pericardium – a broken needle that had travelled to the heart after intravenous heroin administration into the right femoral vein, which was also confirmed on a computed tomography scan. Because of a developing pericardial tamponade, surgical intervention and the extraction of the foreign body was indicated.

Chest pain in adolescent Japanese male mimicking acute coronary syndrome.

Acute chest pain with very elevated troponin level and abnormal EKG in adult population is considered sine qua non to acute coronary syndrome (ACS) unless proved otherwise. Similar presentation in adolescent population is seen less often but raises suspicion for ACS. Most common etiology for chest pain with cardiac enzyme elevation in adolescent population is usually viral myopericarditis. The adolescent population presenting with chest pain and elevated cardiac enzymes should be carefully evaluated for ACS and other etiologies including myocarditis, myopericarditis, pulmonary embolism, acute rheumatic fever, and trauma. We report one Japanese adolescent male with mycoplasma pneumoniae myocarditis who presented to the ER with chest pain, elevated cardiac enzymes, and abnormal EKG.

A patient with chest pain during dobutamine stress echocardiography

A 57-year-old male without any significant past medical history is admitted to the intensive care unit for a suspicion of acute coronary syndrome. He is a non-smoker and mentioned a mild hypercholesterolaemia. He reports an acute constrictive rest chest pain with left arm …

A rare case of multi-chambered fungal endocarditis from a virulent Cunninghamella infection

A 60-year-old woman with graft-versus-host disease after bone marrow transplantation for myelodysplastic syndrome developed sudden onset of angina with elevated troponins raising suspicion for acute coronary syndrome. A left heart catheterization did not indicate any significant coronary artery disease. A transthoracic echocardiogram (TTE) revealed inferior wall hypokinesis with a large mass within the left ventricular (LV) cavity suggestive of thrombus or endocarditis. A recent …

Nonischemic Myocardial Changes Detected by Cardiac Magnetic Resonance in Critical Care Patients with Sepsis

Nonischemic Myocardial Changes Detected by Cardiac Magnetic Resonance in Critical Care Patients with Sepsis

Cardiac computed tomography guided treatment strategy in patients with recent acute-onset chest pain: Results from the randomised, controlled trial: CArdiac cT in the treatment of acute CHest pain (CATCH)

ObjectivesIn patients admitted on suspicion of acute coronary syndrome, with normal electrocardiogram and troponines, we evaluated the clinical impact of a Coronary CT angiography (CCTA)-strategy on referral rate for invasive coronary angiography (ICA), detection of significant coronary stenoses (positive predictive value [PPV]) and subsequent revascularisations, as compared to a function-based strategy (standard care). Secondarily we assessed intermediate term clinical events. Methods and resultsWe randomised 600 patients to a CCTA-guided strategy (299 patients) or standard care (301 patients). In the CCTA-guided group referral for ICA required a coronary stenosis >70% or >50% in the left main, and for intermediate stenoses (50–70%), a stress test was used. A significant stenosis on ICA was defined as a stenosis ≥70% or reduced FFR ≤0.75 in intermediate stenoses (50–70%). Referral rate for ICA was 17% with CCTA vs. 12% with standard care (p=0.1). ICA confirmed significant coronary artery stenoses in 12% vs. 4% (p=0.001), and 10% vs. 4% were subsequently revascularised (p=0.005). PPV for the detection of significant stenoses was 71% with CCTA vs 36% with standard care (p=0.001). Clinical events (cardiac death, myocardial infarction, unstable angina pectoris, revascularisation and readmission for chest pain), during 120days of follow-up, were recorded in 8 patients (3%) in the CCTA-guided group vs. 15 patients (5%) in the standard care group (p=0.1). ConclusionIn patients with recent acute-onset chest pain, a CCTA-guided diagnostic strategy improves PPV for the detection of significant coronary stenoses, and increases the frequency of revascularisations, when compared to a conventional functional approach.

Acute coronary syndrome suspicion in patient with left coronary artery arising from right coronary sinus

We present a case of 73 year-old patient who underwent coronary angiography due to suspicion of acute coronary syndrome without persistent ST segment elevation. The angiographic result showed no lesions that could cause recurrent chest pain,but it also revealed a seldom coronary artery abnormality - left coronary artery arising from right coronary sinus. Performed computed tomography of the chest confirmed the result of the coronarography. But apart from that it found the signs of neoplastic disease which was probably responsible for clinical presentation.

Síndrome de Tako-Tsubo. Discinesia transitoria del ventrículo izquierdo

The Takotsubo syndrome, also called transient apical dyskinesia syndrome, was first described in Japan in the 1990s. It is a rare entity found in almost 1% of all patients with suspicion of acute coronary syndrome. It usually affects postmenopausal women with a few cardiovascular risk factors. It is characterized by angina-type chest pain, electrocardiographic changes, elevation of the enzymes of myocardial injury, absence of coronary obstruction on angiography, and a characteristic left ventricular anteroapical dyskinesia, which returns to normal within a few days. Severe emotional stress is the most common trigger for this syndrome. The aetiopathogenesis of this syndrome remains to be defined. This syndrome has been considered a clinical condition since 2001, when a series of 88 cases was published. It is a disease with a partially known mechanism, characterised by the morphology adopted by the left ventricle secondary to hypokinesis or dyskinesia of the apical segments, and hypercontractility of basal segments. Unlike acute coronary syndrome, patients with left ventricle dysfunction do not have atherothrombotic disease in the coronary arteries. In addition, the alterations described are reversible. Some clinical diagnostic criteria have been proposed, although they are still controversial, as well as in the complementary examinations required for diagnosis.

Examining Renal Impairment as a Risk Factor for Acute Coronary Syndrome: A Prospective Observational Study

This study seeks to examine whether the finding of an abnormal estimated glomerular filtration rate (eGFR) in the emergency department (ED) was associated with acute coronary syndrome in the population of patients presenting for investigation of chest pain. We used prospectively collected data on adult patients presenting with suspected acute coronary syndrome to 2 EDs in Australia and New Zealand. Trained research nurses collected clinical data with a customized case report form. Creatinine measurements were taken on presentation, and the glomerular filtration rate ([GFR]; milliliters per minute per 1.73 m(2)) was estimated with the chronic kidney disease epidemiologic collaboration equation. The primary endpoint was acute coronary syndrome within 30 days of presentation, as adjudicated by cardiologists using standardized guidelines. Logistic regression analyses examined the relationship between eGFR and acute coronary syndrome. Acute coronary syndrome was diagnosed in 421 (21%) of the 1,968 patients recruited. Compared with patients with an eGFR greater than 90 mL/minute per 1.73 m(2), patients with an eGFR between 60 and 90 mL/minute per 1.73 m(2) and patients with an eGFR less than 60 mL/minute per 1.73 m(2) were 1.64 (95% confidence interval 1.10 to 2.44) and 1.70 (95% confidence interval 1.01 to 2.77) times more likely to receive a diagnosis of acute coronary syndrome after controlling for age, sex, hypertension, dyslipidemia, family history of cardiac disease, diabetes, patient history of cardiac disease, cardiac troponin level, and ECG findings. There is an independent association between eGFR and acute coronary syndrome risk in patients presenting to the ED with chest pain; this association is independent of age, traditional cardiac risk factors, medical history, troponin level, and ECG findings. Reduced eGFR should be considered an acute coronary syndrome risk factor, and clinicians should maintain high clinical suspicion for acute coronary syndrome in patients with abnormal renal function results regardless of whether they have known kidney disease, traditional acute coronary syndrome risk factors, or abnormal diagnostic test results. Risk stratification tools should include reduced eGFR as a high-risk feature.

A Case of Acute Aortic Dissection Presenting with Chest Pain Relieved by Sublingual Nitroglycerin

Acute aortic dissection is an uncommon disorder which can have fatal results in the event of treatment delay or misdiagnosis. This case examines a 77-year-old woman presenting with chest pain relieved by nitroglycerin. She was referred to the emergency room with clinical suspicion of acute coronary syndrome (ACS). However, she was later diagnosed with acute aortic dissection and an emergency operation was performed with successful recovery. Aortic dissection may manifest in various ways depending on the site involved and may mimic other disorders such as ACS or pulmonary embolism. Therefore, clinicians must always be aware of aortic dissection and its different clinical manifestations must be understood.

Abstract 220: Longer Door to Balloon Time: Effect of Chronic Kidney Disease on Each Step Leading to PCI

Purpose: Primary percutaneous coronary intervention (PCI) is a time-sensitive process. In high risk populations this time could be longer and affect the reperfusion results. The aim of this study was to examine the door-to-balloon time in patients with chronic kidney disease (CKD) and determine the influence of CKD at each step leading to PCI. Methods: We conducted a retrospective study of patients admitted at an academic medical center for suspicion of acute coronary syndrome from 2004 to 2011. ICD9 codes were used to identify patients with myocardial infarction (MI) and comorbidities. CKD was defined using an estimated glomerular filtration rate (GFR) &lt;60 mL/min/1.73 m 2 . ST segment elevation (STEMI) status was ascertained at hospital admission. In our hospital, date-times of each step (diagnostic ECG, alert for potential MI) are monitored. Non-parametric tests were used to compare time intervals according to GFR. Because the door-to-balloon time is right skewed, we log transformed time and modeled it as gamma distributed using a generalized estimating equation (GEE) to examine its association with CKD, after adjusting for age, gender, race, hypertension, congestive heart failure, and diabetes. Results: Our study population included 712 patients with STEMI, of whom 138 (19.4%) had CKD (see table). Door-to-balloon time was longer in patients with GFR &lt;30. Likewise diagnostic ECG-to-MI alert time was longer in patients with GFR &lt;30 whereas MI alert-to-balloon time was not different between those with and without CKD. Results from the GEE showed that GFR&lt;30 was an independent predictor of door-to-balloon time. Conclusion: Patients with severe CKD have a longer door-to-balloon time than patients without CKD. This difference seems to be due to a longer time-interval between the time the diagnostic ECG is made and the time the MI alert is called. This delay in initiating PCI could be related to the misleading ECG (left ventricular hypertrophy, electrolyte and conduction abnormalities) frequently found in patients with CKD.

Transcriptional Activity of Tumour Necrosis Factor α (TNF‐α) in Patients with Subclinical Coronary Atherosclerosis – Preliminary Results

The most frequent cause of ischaemic heart disease is coronary arteriosclerosis. This study was aimed at assessing gene expression of TNFA and its two receptors (TNFR1, TNFR2), as well as determining coronary artery calcium score (CACS) in the context of occurrence of classical risk factors in patients with subclinical atherosclerosis of coronary vessels. The study involved 47 subjects with complaints of chest pain and suspicion of acute coronary syndrome or stable coronary disease. Additionally, CACS was assessed by 64-slice computerized tomography. QRT-PCR molecular studies were performed using RNA isolated from peripheral blood mononuclear cells. Preliminary results of molecular studies on patients with subclinical coronary atherosclerosis revealed a significantly lower numbers of TNFR1 and TNFR2 gene copies as compared with healthy subjects. In addition, it can be demonstrated that among classical risk factors hypertension is of substantial importance in the progression of coronary arteries’ calcification, and that in the examined group CACS increases together with the rising number of classical risk factors involved. No correlation was observed, however, between expression of TNFA, TNFR1 and TNFR2 genes and the value of CACS. Conclusions: 1. The occurrence of hypertension facilitates initiation and progression of arteriosclerotic lesions in blood vessels including the coronary ones; the raised number of circulatory disease classical risk factors involved correlates with elevated calcification of coronary arteries as shown by 64‐slice computerized tomography scans. 2. Significantly decreased numbers of TNFR1 and TNFR2 gene copies observed in the investigated group may play a significant role in initiation and progression of arteriosclerosis.

Prevalence and determinants of atypical presentation of acute coronary syndrome

Knowledge of the characteristics of patients with atypical presentation of acute coronary syndromes may contribute to increased sensitivity in diagnosis in a given population. The purpose of this study is to quantify the prevalence of atypical presentation, to identify its determinants, and to describe the presenting symptoms in cases of acute coronary syndrome at the emergency department of Hospital São João, Porto. Systematic sample of 288 emergency admissions with a confirmed diagnosis of acute coronary syndrome in 2007. Atypical presentation was defined as absence of chest pain and/or syncope. The prevalence of atypical presentation was 20.5% [95% confidence interval (CI): 16.0 to 25.5], with no important variation by gender. It increased with age and was more frequent in cases of ST-segment elevation myocardial infarction. In multivariate analysis, atypical presentation was associated with age [>70 versus ≤ 50 years, odds ratio (OR)=3.45; 95%CI: 1.03-11.61] and it was about four times less likely in the presence of history of ischemic heart disease, hypertension, dyslipidemia and smoking. A history of heart failure was independently associated with a higher likelihood of acute coronary syndrome with atypical presentation (OR = 4.15, 95%CI 1.50-11.46). Among the 223 cases who had chest pain or discomfort, a growing, oppressive, prolonged (longer than 30 minutes), recurrent and episodic pain prevailed. Among other symptoms, dyspnea was the most frequently reported, either as the main symptom in cases of atypical presentation or concurrently with typical symptoms. Factors associated with atypical presentation are consistent with those described in other populations. Using routine clinical data allowed access to a large data base on a representative sample of patients admitted to the emergency department of a third-level hospital that serves a large part of the local urban population. In medical records, data are unstandardized and heterogeneous in validity and detail. One fifth of the episodes of acute coronary syndrome have atypical presentation, and this proportion is higher in older ages. Previous history of ischemic heart disease or its classical risk factors are associated with typical symptoms, while heart failure is associated with atypical presentation. Presentation in atypical cases is highly variable and does not allow the identification of a pattern that would justify lowering the threshold for suspicion of acute coronary syndrome.

Comparison of image characteristics of plaques in culprit coronary arteries by 64 slice CT and intravascular ultrasound in acute coronary syndromes

PurposeTo evaluate plaque image characteristics in coronary artery culprit-lesions in subjects with acute coronary syndromes (ACS), we retrospectively compared coronary arterial images by 64-slice CT before conventional-coronary-angiogram with those by intravascular ultrasound (IVUS). Materials-and-methodsRetrospective analysis of coronary arterial images from thirty-one subjects (26-males, mean age 59.3±12.0years) exhibiting acute symptoms with suspicion of ACS, where either (1) ECG was un-interpretable or (2) ECG was non diagnostic/cardiac biomarkers was equivocal; with significant stenosis on emergent 64 slice CT and subjects were finally diagnosed as having ACS confirmed by conventional-coronary-angiogram, followed by IVUS before coronary-intervention. After principal culprit-lesion components were classified into 1) thrombus, 2) soft plaques, and 3) fibrotic plaques by IVUS, corresponding culprit-lesion CT values were measured (two-observers). ResultsNineteen and 12 of 31 subjects were finally diagnosed as unstable angina pectoris and non-ST elevation acute myocardial infarction respectively. Main culprit-lesion components of ACS were identified on MSCT in all subjects. Culprit-lesion CT values diagnosed as soft plaques by IVUS (n=6, 32.9±8.7HU) were not lower than those of thrombi (n=18, 43.2±10.7HU, p=0.268); both values were significantly lower than those of fibrotic plaques (n=7, 82.5±22.6HU) (both p<0.01). Calcification, spotty calcification, and positive arterial remodeling were observed in 67.7%, 61.3%, 58.1% (IVUS) and 58.1%, 51.6%, 74.2% (MSCT), respectively (all p=NS). CT value reproducibilities and culprit-lesion areas, were 0.87 and 0.86, respectively (two analyzers). Conclusions64-slice CT can non-invasively evaluate image characteristics in coronary artery culprit-lesions in ACS subjects accurately; this may help to differentiate soft plaques or thrombi generated by plaque rupture from fibrotic plaques.