Int J Cardiovasc Imaging DOI 10.1007/s10554-015-0763-2
ORIGINAL PAPER
Cardiac CT angiography for evaluation of acute chest pain Nam Ju Lee1 • Harold Litt1
Received: 4 August 2015 / Accepted: 31 August 2015 Ó Springer Science+Business Media Dordrecht 2015
Abstract Chest pain is the second most common emergency department (ED) presentation in the United States. Cardiac computed tomography angiography (CCTA) now plays an important role in the evaluation of patients with suspected acute coronary syndrome in the ED setting. In this article, we review the available techniques focused on the use of CCTA to evaluate patients fosr coronary atherosclerosis for timely triage of acute chest pain. Keywords Acute coronary syndrome Chest pain Coronary CT angiography Atherosclerosis Emergency department
present with unstable angina, acute myocardial infarction, or sudden coronary death [5], therefore, timely triage of ACS is important as it effects treatment and prognosis. Also timely triage may save significant costs. Using coronary CTA to clear patients instead of admitting patients for a rule out approach with serial troponin has the potential to save significant costs to the health care system. In this article, we review the role of cardiac CT angiography (CCTA) in patients with acute chest pain to diagnose and manage ACS caused by coronary atherosclerosis in the setting of the emergency department.
Risk assessment Introduction There is nearly one death from heart disease every 38 s in the United States [1]. Acute chest pain is the single most common complaint of patients older than 15 years of age presenting to the emergency department (ED) [2] and accounts for about 4 % of ED visits in the United States [3]. Origins of chest pain include diseases of the heart, aorta, pulmonary system, esophagus, upper abdomen, chest wall, and even psychiatric disorders. Determination of the etiology of the chest pain is often difficult, although different types of chest pain are classically ascribed to different corresponding diseases. Acute coronary syndrome (ACS) is estimated to be responsible for 20 % of all clinical encounters for acute chest pain [4]. Patients with ACS & Harold Litt
[email protected] 1
Department of Radiology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia, PA, USA
The initial step in evaluation of potential ACS in the ED is assessment of patient risk; this may be performed using scales such as the Thrombosis in Myocardial Infarction (TIMI) score, including clinical and medical history, coronary artery disease risk factors, electrocardiogram (ECG) results, and serum cardiac enzyme levels [6]. In approximately 10 % of all ED chest pain patients, with a TIMI risk score of zero combined with negative serial cardiac biomarker testing, the patient may be considered at low risk and discharged directly from the ED [7]. The presence or absence of specific symptoms is not reliable when used to rule out myocardial ischemia [8], and risk factors (hypercholesterolemia, hypertension, family history, and tobacco use) remain poor predictors of ACS [9, 10]. The standard 12-lead ECG cannot exclude ACS conclusively because diagnostic ECG findings are present only in a minority of patients, although it is the single best test to identify ST-segment elevation MI (STEMI) [11, 12]. Despite improvement in cardiac biomarkers (Creatine kinase, CK-MB, Myoglobin, Troponin I, Troponin T) for
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early diagnosis and risk stratification of acute MI [13–16], they are not universally elevated in patients with unstable angina or transient myocardial ischemia [17]. Therefore, negative markers cannot exclude ACS entirely and evaluation is still needed according to their clinical presentations. Patients with low-intermediate TIMI score without initial enzyme level elevation or ECG changes are typically admitted for complete evaluation with further enzyme analysis and often for myocardial stress imaging, whereas patients with a high-risk score are referred for intravenous (IV) heparin and further investigation with catheterization for intervention [18]. However, the reported 2–4 % rate of missed diagnosis of ACS [19–21] may expand the number of tests and hospitalizations in relatively low-risk populations with chest pain without definite evidence of ACS [22].
Evidence for CCTA in the ED The application of CCTA in the ED is based on trial data and observation from a limited number of centers [23–28] and CCTA is now seen as a viable alternative to functional testing in the evaluation of patients with acute chest pain in the ED [29–31]. Early utilization of CCTA in the ED for appropriately selected patients with a low to intermediate risk of ACS identifies low-risk patients quickly without the added delay of serial biomarkers or prolonged observation. It facilitates more rapid discharge from the ED compared to those undergoing non-CCTA standard care including serial ECGs, cardiac biomarkers, and subsequent cardiac testing such as exercise testing, stress perfusion imaging, or cardiac catheterization without a statistically significant difference in major adverse cardiac events (MACE) [25, 29– 34]. CCTA has shown its safety and efficiency in excluding coronary artery disease or relevant stenosis for advanced risk stratification over the past decade in the setting of ambiguous acute chest pain of a low to intermediate risk of ACS with 86–100 % sensitivity, 92–98 % specificity, 93–100 % negative predictive value, 50–90 % positive predictive value [23, 35–38]. Gallagher and colleagues [24] showed that CCTA is comparable to myocardial stress perfusion imaging in terms of safety and accuracy for excluding or diagnosing ACS. In a prospective cohort trial of 568 patients in the ED with low TIMI score, 84 % of patients were discharged based on a negative CCTA without adverse outcomes in 30 days with only one potential cardiac death at 1-year follow-up [27, 39]. ACRIN PA 4005 was a randomized controlled study of CCTA versus usual care for low-to-intermediate-risk patients presenting with a possible acute coronary syndrome. Of 640 patients with a negative CCTA
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examination, none died or had a myocardial infarction within 30 days and patients in the CCTA group had a higher rate of discharge from the ED (49.6 vs. 22.7 %), a shorter length of stay (LOS) (median, 18.0 vs. 24.8 h), and a higher rate of detection of coronary disease (9.0 vs. 3.5 %) compared with patients receiving traditional care [30]. CCTA also reduces cost in addition to reduction in diagnostic time in the intermediate-risk population [23, 39]. However, patients with indeterminate lesions or nondiagnostic CCTA will be referred for stress testing to evaluate the physiologic relevance of intermediate lesions. There are a small number of uninterpretable cases due to patient motion or unexpected heart rate variability. Our goal is that fewer than 5 % of studies will be deemed uninterpretable; this is accomplished only with strict heart rate control and patient education about what will happen during the test. The Computed Tomographic Angiography for the Systematic Triage of Acute Chest Pain Patients to Treatment (CT-STAT) trial showed that CCTA and stress SPECT myocardial perfusion imaging led to a similar number of patients referred to invasive coronary angiography, 6.9 and 6.2 %, respectively, similar to findings in ACRIN PA 4005. Time to diagnosis and hospital costs were significantly reduced with CCTA, to an average of 3 h compared with 7 h for those who received stress SPECT MPI; direct costs were reduced by 38 %, from roughly $3500 to $2000. In the ROMICAT II trial, 1000 patients with symptoms suggestive of ACS were randomized to an early CCTA or standard ED evaluation. Similar to the other studies, ROMICAT II demonstrated a shorter LOS for patients who underwent CCTA than standard evaluation and ED costs were lower. However, catheterization and revascularization rates were higher in the CCTA arm, leading to higher inpatient costs and overall cost neutrality. Women in the CCTA arm had greater reduction in LOS, lower hospital admission rates, and a smaller increase in cumulative radiation dose than men when comparing ED strategies (pinteractions B 0.02) [40]. While women had lower ACS rates than men, sex differences in LOS persisted after adjustment for baseline differences including ACS rate (pinteraction \ 0.03). LOS was similar between sexes with normal CCTA findings (p = 0.11).
Performing CCTA in the ED Patients with a low to intermediate risk of ACS are usually judged clinically according to initial risk assessment data including clinical history, ECG, biomarkers, and TIMI score of 0–2. CCTA may be performed for patients with negative prior stress test or even for those with TIMI score 3–4 and this allows cardiac CTA to be ordered for
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approximately 60–70 % of patients [41, 42]. Previously, the North American Society of Cardiovascular Imaging (NASCI) and the European Society of Cardiac Radiology (ESCR) published interim guidance for utilization of CCTA in the ED [43]. Multiple societies, including the American College of Cardiology and the American College of Radiology, are currently collaborating to create appropriate use criteria for the imaging of ED patients presenting with chest pain (Rybicki, et al. JACR, in press). Patients with a serum creatinine level of greater than 1.5 mg/dL or a severe allergy to iodinated contrast material and those who are pregnant are not eligible for CCTA. Conditions that may be not suitable for CCTA are active asthma or other contraindications to b-blocker administration, irregular heart rhythms such as atrial fibrillation, and weight more than 150 kg, depending on the specific CT technology in use. Heart rate control to \70 bpm is required for high quality CCTA, depending upon the technology in use [44]. A fast-acting b-blocker with a short half-life, typically oral metoprolol, is given at least 1 h before imaging for patients with fast heart rates when there is no contraindications, e.g., active or unstable small airways disease, hypotension, sinus bradycardia, or recent cocaine use. The initial dose is 50–100 mg with additional doses up to 200 mg if needed [45]. IV metoprolol can be administered in the CT suite, and the effect occurs typically in 5–10 min; 5 mg IV can be given initially, with additional doses up to 20 mg if required. For patients with contraindications to b-blockers, calcium channel blockers, preferably diltiazem with the least negative inotropic effect, can be considered as an alternative (initial IV bolus of up to 0.25 mg/kg). Careful monitoring of vital signs is required with IV medication. Utilizing sublingual nitroglycerin before contrast-enhanced images is valuable for improving the contrast-to-noise ratio and vessel visualization by vasodilation of the coronary arteries [46, 47]. Contraindications to nitroglycerin include recent phosphodiesterase inhibitor therapy, commonly used for erectile dysfunction or pulmonary hypertension, hypotension, and critical aortic stenosis.
Alternative tests In patients with low to intermediate pretest probability, other tests with high negative predictive value to rule in or rule out ACS or myocardial infarct (MI) to enable early discharge include rest CMR, echocardiography, and SPECT MPI, though these must be performed while the patient is experiencing chest pain. Resting SPECT MPI with technetium-99m sestamibi is useful in the setting of suspected ACS [48–51] and its use in the ED setting resulted in earlier discharge, lower cost, and fewer
unnecessary admissions [52–54]. Observational studies demonstrated its high negative predictive value to rule out MI or short-term cardiac events. However, a considerable limitation of resting SPECT MPI in ED patients is the limited availability of tracers and interpreting personnel as well as decreased accuracy when not performed during an episode of chest pain. Resting 2-dimensional (2D) echocardiography provides information by evaluating wall motion and ejection fraction rapidly and noninvasively [55, 56]. However, the positive predictive value is only 0–44 % [55, 57, 58] with difficulty distinguishing acute from chronic ischemia. In addition, coronary stenosis cannot be evaluated unless the patient has a wall motion abnormality; as with multiphase CCTA, rest echo may be useful for evaluation nonischemic causes of chest pain. Cardiac MR (CMR) can image coronary anatomy, ventricular function, myocardial perfusion, and myocardial fibrosis/scar. In observational studies, CMR has a sensitivity of 70–85 % to detect ischemic heart disease [59–61] and coronary MR angiography showed 72 % accuracy detecting stenosis. Although a normal CMR is associated with good prognosis and a very low risk, lower spatial resolution and limited availability compared to CCTA limit its clinical application in the ED setting [62]. Conventional catheter angiography, considered a gold standard for diagnosis of coronary artery disease, should be reserved for use as a confirmative test and for intervention for patients with significant stenosis or occlusion who will undergo intervention with certain likelihood rather than for initial evaluation of patients at less than high risk for ACS. Hence, invasive catheterization should be a purely therapeutic option. Coronary artery calcification (CAC) can be seen in most patients with ACS or sudden cardiac death and it has been established as a quantitative marker and indicator of atherosclerosis using the Agatston-score [63–66]. The role of calcium scoring in ED patients with suspected ACS continues to be debated, because it has been shown that calcium scores alone cannot be used to determine risk in patients presenting with potential ACS in the ED and does not add prognostic value for acute events although it may be useful for long-term management of cardiac risk in outpatients. One study showed that a significant number of patients with a zero CAC had CTA findings [67], therefore, CTA is better than CAC scoring in determining the atheroma burden, especially in patients with risk factors. However, higher Agatston score is correlated with increased risk of cardiac events and worse overall prognosis [68]. Framingham risk score combined with coronary calcium score can improve 10-year risk stratification of asymptomatic people, especially those with intermediate risk (Framingham risk score 10–20 %) [69]. Calcium scoring may be recommended in this group to support clinical decision making, particularly whether to start
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aggressive medical therapy. The risk is highest when the Agatston score is above 400. Cardiovascular risk increases proportionally to the amount of calcium and an annual progression of more than 15 % enhances the risk of myocardial infarctions although positive predictive value of CAC progression is low as a marker of risk [70–72]. After myocardial infarction, patients have higher CAC progression than event-free subjects [73]. CAC scoring does not necessarily add relevant information in high or low risk populations [35]. While an unenhanced series may be useful to customize the CCTA scan field and other parameters to reduce doses, the effective dose of a calcium scoring acquisition is now similar to CCTA doses obtained with lower tube voltage technique, and therefore its value in the ED is uncertain. [74].
Stenosis and plaque in ED CCTA studies A study from Miller et al., showed that a diameter stenosis of 25–50 % on cardiac CTA is unlikely to be related to ACS and there is a very low MACE rate (0.5 %) after ED presentation in the following 30 days in those patients [75]. The result is different than the ROMICAT-I trial, in which 2.6 % of ED patients with visible atherosclerosis but less than 50 % stenosis at CCTA experienced ACS, as identified by serial cardiac markers but not by stress testing [28]. All patients had small vessel disease, which is associated with a low incidence of adverse events and mortality, and is not generally amenable to revascularization [76–80]. Nonetheless, small vessels are a limitation of CCTA evaluation [81], and therefore, serial cardiac makers may be beneficial in patients with less than 50 % stenosis on CCTA but further testing such as stress testing is not indicated during the index visit [75]. Short-interval outpatient follow-up is important to establish strategies for primary prevention. The ROMICAT-I trial demonstrated a 77 % sensitivity of a stenosis C50 % for detection of ACS [28]. In the ROMICAT-II study, a stenosis C50 % was detected in 78 % of patients with ACS, which is similar to invasive angiography studies that observed an absence of significant stenosis in 12–14 % of patients with ACS [82]. A clinical registry by van Velzen et al. [83] showed sensitivity, specificity, and positive and negative predictive values to detect significant CAD on CTA were 100, 87, 93, and 100 %, respectively. During mean follow-up of 13.7 months, no cardiovascular events occurred in patients with a normal CTA examination. In patients with nonsignificant CAD on CTA, no cardiac deaths or myocardial infarctions occurred and only 1 patient underwent revascularization due to unstable angina. In patients presenting with acute chest pain, an excellent clinical performance for the non-invasive assessment of significant CAD was
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demonstrated using CTA. Normal or non-significant CAD on CTA predicted a low rate of adverse cardiovascular events and favorable outcome during follow-up [83]. ROMICAT-I demonstrated limited positive value of a stenosis [50 % at CCTA for ACS because matching perfusion abnormalities on SPECT MPI testing were seen in only 46 % of these patients [84]. The optimal management of patients with intermediate lesions at CCTA remains uncertain and may result in an increased frequency of downstream testing and interventions [29–31, 85]. However, patients with significant stenosis on CTA cannot be discharged from the ED after initial troponin and ECG [29– 31, 85]. Coronary artery plaque features may assist in further stratifying risk beyond that obtained using percent stenosis [86–88]. Atherosclerotic lesions can be characterized as calcified, non-calcified and partially calcified (mixed plaques) on CT (Fig. 1). A lack of coronary calcium does not definitely exclude coronary stenosis and a high amount of calcium does not necessarily correlate with angiographic luminal stenosis or vulnerability of plaques [89, 90]. Frequently ACS develops from relatively mild or moderate lesions angiographically in the relatively early stage of atherosclerosis [91–93]. Reported features of high risk plaque are large plaque volume, positive remodeling (Fig. 2), spotty calcium, greater proportion of non-calcified plaque, low mean and minimal CT attenuation value (Hounsfield units, HU), and contrast-enhanced rim seen around the central filling defect (napkin-ring sign) [87, 94– 100], which are similar to high risk findings on intravascular imaging (positive remodeling, larger plaque area, spotty calcium, and large necrotic core) [101, 102] as well as histology. These changes can directly be visualized on CCTA but will not appear on invasive angiography because the vessel wall is invisible [35]. Multi-energy imaging techniques may assess plaque composition [103] and myocardial perfusion providing prognostic information [104]. Dual energy CT may assist in distinguishing densely calcified plaques from other plaque types although further plaque discrimination such as fibrous versus lipid rich plaque is not currently possible [105]. High-risk plaque features have been associated with an increased risk for future cardiovascular events in patients with stable chest pain syndromes [88, 106, 107]. Pflederer et al. showed that these findings are more often seen with culprit lesions in patients with ACS compared with similarly stenotic plaques in patients with stable angina [63]. Studies reported 5–15 % prevalence of high-risk plaque features in the acute chest pain population, patients undergoing invasive coronary angiography, and in nonculprit vessels of patients with ACS (Providing Regional Observations to Study Predictors of Events in the Coronary Tree, PROSPECT trial) [85– 88, 97, 98]. The value of high-risk plaque features for the
Int J Cardiovasc Imaging Fig. 1 Coronary atherosclerotic disease. A Noncalcified plaque in the proximal LAD, which is difficult to differentiate from thrombosis by CT. B Mixed plaque with a small focus of calcification peripherally in the main coronary bifurcation. C Mixed plaque, predominantly noncalcified plaque in the proximal LAD. D Predominantly calcified plaques in the LAD and LCx
diagnosis of ACS in patients with significant stenosis was demonstrated in the ROMICAT-I trial [108]. In the ROMICAT II trial, high-risk plaques on coronary CTA increased the likelihood of ACS independent of stenotic CAD and clinical risk assessment (age, sex, and number of cardiovascular risk factors) in patients presenting to the ED with acute chest pain but negative initial electrocardiogram and troponin [85]. Interestingly, nonalcoholic fatty liver disease (NAFLD) was reported to be associated with advanced high-risk coronary plaque, independent of traditional cardiovascular risk factors and the extent and severity of coronary artery disease [109]. Chronic total occlusions (CTOs) of a coronary artery is defined as the total occlusion of the vessel on invasive angiography with complete interruption of antegrade blood flow and an age of the occlusion C3 months proven by prior angiography or estimated from the clinical course [110]. CCTA can directly visualize morphological characteristics of CTOs, which influence the success rates of PCI for and it is useful to predict the likelihood of successful recanalization [111–113]. CCTA is also useful for planning other interventions by providing evaluation of total lesion length (calcified plus non-calcified plaque), reference segment diameter, angulation of the aortic root, and better visualization of ostial lesions than catheter angiography. This information may assist in selection of appropriate stent length and diameter and result in shortened procedure times and improved outcomes [114, 115].
Blooming artifact from densely calcified plaque limits the accurate evaluation of stenosis and the degree of stenosis is often overestimated [116]. Despite concerns about image quality in patients with calcium score over 400, a recent study showed that only a small percentage of these studies in ED patients are uninterpretable [117]. Newer dual-energy technology using simultaneous or alternating imaging at two different x-ray tube potentials allows improved quantification of calcified plaque by reducing tissue blooming and beam hardening beyond single-energy MDCT [103]. At our institution, we have no threshold set for aborting CCTA, and a radiologist may decide to proceed with scanning based on the likelihood of a diagnostic study even in patients with high calcium score. Evaluation of coronary stent patency is limited due to blooming artifacts similar to dense calcium [118]. However, stents are unlikely to be present in a patient with low to intermediate risk of ACS presenting to the ED.
Non-atherosclerotic causes of chest pain Myocardial bridging, an intramyocardial segment of an epicardial coronary artery coursing within the myocardium, is present in about one-third of adults [119]. In the majority of cases, systolic compression of the tunneled segment remains clinically silent. With provocative testing in
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Int J Cardiovasc Imaging Fig. 2 48 year-old male with intermittent breif chest pain. High cholesterol, nonsmoker, normal troponin. There is long segmental noncalcified plaque with high grade stenosis in the LAD with positive remodeling (A). Stent was placed. Note increased diameter of the stenotic artery (C) compared to the proximal (B) and distal (D) to the stenosis
patients with angiographically normal coronary arteries, myocardial bridges are revealed in B40 % of cases by increasing systolic compression [120]. Rare complications of myocardial bridging include angina, myocardial ischemia, myocardial infarction, left ventricular dysfunction, myocardial stunning, paroxysmal AV blockade, exerciseinduced ventricular tachycardia and sudden cardiac death [121–124]. The likelihood of ischemia also increases with the intramyocardial depth of the tunneled segment, however, there is no consistent association between the patient’s symptom and the length, depth of the tunneled segment or the degree of systolic compression [125, 126]. CCTA is ideal to demonstrate the anatomic course of coronaries and caliber change throughout the cardiac cycle when retrospectively ECG gated CCTA is employed. About 80 % of coronary artery anomalies are benign and incidental findings at the time of catheterization [127]. Although the significance of coronary anomalies is mostly unclear, potentially serious anomalies which include ectopic coronary origin from the pulmonary artery or opposite aortic sinus, single coronary artery, and large coronary fistulae can result in
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angina pectoris, myocardial infarction, heart failure, arrhythmias, and sudden cardiac arrest [127]. Younger patients in their first three decades with isolated coronary artery anomalies are at risk of dying, especially with exercise [128]. Sudden cardiac arrest (SCA) secondary to congenital anomalous coronary artery disease occurs due to insufficient coronary flow by the anomalous LCA to meet elevated left ventricular myocardial metabolic demand, usually during exertion or exercise. In a majority of previously reported cases, SCA was triggered by exertion and most of these patients have a positive exercise stress test [129]. Contributing factors to an increased resistance in the LCA include compression between the great vessels, a slit-like ostium, myocardial bridging, or unfavorable geometry [130]. High risk defects include those involved with the proximal coronary artery or coursing of the anomalous artery between the aorta and pulmonary trunk [128]. Left anterior descending coronary arteries arising from the right cusp with an inter-arterial course have been considered malignant and anomalous coronary origins can be associated with acute chest pain [128].
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Conclusions CCTA has demonstrated its safety and efficiency in the ED setting to evaluate patients with suspected ACS related to coronary atherosclerosis. Evaluation of the association between plaque features and risk of ACS and outcomes is ongoing. Compliance with ethical standards Conflict of interest Nam Ju Lee declares that he has no conflict of interest. Harold Litt grants funding from Siemens Medical Solutions for unrelated CT research.
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