Comparison of Exercise Treadmill Testing With Cardiac Computed Tomography Angiography Among Patients Presenting to the Emergency Room With Chest Pain The Rule Out Myocardial Infarction Using Computer-Assisted Tomography (ROMICAT) Study

Department of Medicine (Cardiovascular Division) and Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA.
Circulation Cardiovascular Imaging (Impact Factor: 5.32). 02/2012; 5(2):233-42. DOI: 10.1161/CIRCIMAGING.111.969568
Source: PubMed


The aims of our study were to (1) examine how data from exercise treadmill testing (ETT) can identify patients who have coronary plaque or stenosis, using CT angiography (CTA) as the reference standard, and (2) identify patient characteristics that may be used in selecting ETT versus CTA.
The Rule Out Myocardial Infarction Using Computer-Assisted Tomography (ROMICAT) trial was an observational cohort study of acute chest pain patients presenting to the emergency department with normal initial troponin and a nonischemic ECG. Univariate and multivariable analyses were performed to assess the relationship of baseline clinical data and ETT parameters with coronary plaque and stenosis on CTA. Of the 220 patients who had ETT (mean age, 51 years; 63% men), 21 (10%) had positive results. A positive ETT had a sensitivity of 30% and specificity of 93% to detect >50% stenosis. The sensitivity increased to 83% after excluding uninterpretable segments and evaluating the ability to detect a >70% stenosis. Predictors of plaque included older age, male sex, diabetes, hypertension, hyperlipidemia, lower functional capacity, and a lower Duke Treadmill Score. Both a positive ETT and a low Duke Treadmill Score were significant univariate and multivariable predictors of stenosis >50% on CTA Whereas the prevalence of stenosis by CTA was greater among patients with more risk factors, coronary stenosis was not present among men <40 years old or women <50 years old or individuals who achieved at least 13 metabolic equivalents on ETT.
Among low- to intermediate-risk patients with acute chest pain, a positive ETT has a limited sensitivity but high specificity for the detection of >50% stenosis by CTA. Although patients with a high number of clinical risk factors are more likely to have obstructive coronary artery disease, those who are young or who would be expected to have a very high exercise capacity are unlikely to have coronary stenosis and therefore may benefit from initial ETT testing instead of CTA.

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    • "Functional Relevance of CAD by CCT. The advancement of CCT has enabled the noninvasive evaluation of coronary artery stenosis in several clinical scenarios [44] [45] [46] [47] [48] with a low radiation exposure [49] [50] [51]. Despite high negative predictive value, factors such as high heart rate, arrhythmia, obesity, and high coronary calcium burden continue to limit the overall evaluability and positive predictive value of CCT [52] [53]. "
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    ABSTRACT: Coronary artery disease (CAD) is one of the leading causes of morbidity and mortality and it is responsible for an increasing resource burden. The identification of patients at high risk for adverse events is crucial to select those who will receive the greatest benefit from revascularization. To this aim, several non-invasive functional imaging modalities are usually used as gatekeeper to invasive coronary angiography, but the diagnostic yield of elective invasive coronary angiography remains unfortunately low. Stress myocardial perfusion imaging by cardiac magnetic resonance (stress-CMR) has emerged as an accurate technique for diagnosis and prognostic stratification of the patients with known or suspected CAD thanks to high spatial and temporal resolution, absence of ionizing radiation, and the multiparametric value including the assessment of cardiac anatomy, function, and viability. On the other side, cardiac computed tomography (CCT) has emerged as unique technique providing coronary arteries anatomy and more recently, due to the introduction of stress-CCT and noninvasive fractional flow reserve (FFR-CT), functional relevance of CAD in a single shot scan. The current review evaluates the technical aspects and clinical experience of stress-CMR and CCT in the evaluation of functional relevance of CAD discussing the strength and weakness of each approach.
    BioMed Research International 01/2015; 2015. DOI:10.1155/2015/297696 · 3.17 Impact Factor
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    • "Coronary CT angiography (CCTA) has emerged as an effective tool for both outpatient and emergency department (ED) evaluation of low to intermediate risk patients presenting with acute chest pain syndromes [1] [2] [3] [4] [5] [6]. CCTA has also been shown effective as a complementary test in patients with equivocal or abnormal noninvasive results without high risk features [7]. "
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    ABSTRACT: Introduction: The purpose of this study is to investigate the cost and resource utilization due to recurrent chest pain evaluations after initial evaluation with coronary computed tomography angiography (CCTA) based upon coronary artery disease (CAD) burden. Methods: CCTA results of 1,518 patients from January 2005 until July 2012 at a single high volume, tertiary center performed in the inpatient or outpatient setting for cardiac symptoms. Patients were grouped based on the CCTA results into no CAD, non-obstructive CAD (<50% maximal diameter stenosis), or obstructive CAD (≥50% stenosis). Re-evaluation for chest pain syndrome after initial CCTA, as well as rates of major adverse cardiovascular events (MACE) defined as the incidence of all-cause mortality, non-fatal MI, ischemic stroke, and late revascularization (>90 days following CCTA) were evaluated. Results: Over a review period of six years with a resultant median follow-up period of 22 months (IQR25-7513 - 34 months), the MACE rate was significantly higher with obstructive CAD compared to both non-obstructive CAD and no CAD (8.9% vs. 0.7%, p<0.001; 8.9 vs. 1.6%, p<0.001). In the 1518 patients evaluated, the mean age increased with increasing CCTA disease burden (p<0.001) with equal gender distribution amongst the groups. 174 patients (11.5%) underwent re-evaluation for acute chest pain after index CCTA with rates significantly higher with obstructive CAD compared to both non-obstructive CAD and no CAD (7.5% vs 13.9% vs 17.8%, p<0.001). The incidence of repeat testing was more frequent in patients with obstructive CAD (no CAD 36.5% vs non-obstructive CAD 54.9% vs obstructive CAD 67.7%, p=0.015). Conclusion: Absence of obstructive disease on CCTA is associated with much lower rates of subsequent evaluations for chest pain and repeat testing with associated low MACE event rates over 6-year review period and median follow-up of 22 months.
    International Scholarly Research Notices 04/2014; 2014(157). DOI:10.1155/2014/304825
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    ABSTRACT: Coronary CT angiography (CTA) has become a well-accepted imaging modality in the evaluation of coronary artery disease (CAD) due to its high negative predictive value. The ability to exclude CAD in patients presenting with chest pain in a low to intermediate risk population makes it very useful in emergency departments for optimizing resource utilization and reducing expenditure. The limited availability of trained cardiac imagers is a potential obstacle in implementing this strategy. Towards the goal of prompt and accurate interpretation of coronary CTA, there has been a recent interest in the development of automated coronary CTA interpretation and reporting. This article aims to review the current applications and scientific evidence on the utility of automated techniques for interpretation and reporting of coronary CTA.
    Current Cardiovascular Imaging Reports 06/2013; 6(3). DOI:10.1007/s12410-013-9201-9
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