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Coronary ct angiography in the er

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Stephen Fleet
Stephen Fleet

This document discusses using coronary CT angiography (CCTA) to evaluate patients presenting to the emergency department with chest pain. It provides advantages of CCTA over the current standard of care, which can be time-consuming and costly. CCTA is a quicker and more efficient test that can actually show if significant blockages are present. Several studies demonstrate CCTA has high sensitivity, specificity, and negative predictive value. For patients found to have no blockages on CCTA, it allows safe discharge without further testing. The document proposes a new chest pain management pathway that begins with risk stratification and uses CCTA for low-to-intermediate risk patients to efficiently rule out blockages.

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Coronary CT Angiography in the ER STEPHEN FLEET, M.D. CARDIOLOGY SEPTEMBER 2021
Obstructive CAD Left Main
Chest Pain Types relative to CAD Clearly atypical CP Low to intermediate probability of CAD/ACS Most probably ACS (MI or unstable angina). We are concerned with the 2nd type.
Current Standard of Care History and Physical EKG Troponins If negative and depending on time of day, wait in ER or admit Nuclear stress test Discharge if stable
Positive Nuclear Study
Negative Study
Problems with SOC Time Consuming Costly Limited Sensitivity and Specificity
EVINCI STUDY 2015
Obstructive CAD at Cath: NCDR 2005-2007 Patel MR, Peterson ED, Dai D, Brennan JM, Redberg RF, Anderson HV, Brindis RG, Douglas PS. NEJM. 2010 Mar 11;362(10):886-95
NEW PARADIGM WHY NOT START WITH AN ANATOMIC STUDY, WHICH CAN ACTUALLY SHOW YOU IF THERE IS SIGNIFICANT NAMELY, CORONARY CT ANGIOGRAPHY.
ADVANTAGES READILY AVAILABLE NOW AT CHESHIRE MEDICAL CENTER TIME SAVING; MORE EFFICIENT LESS COSTLY SUPPORTED BY MULTIPLE STUDIES OVER APPROXIMATELY 15 YEARS
METHODS - CTA 0.5-0.625 mm slices Single Breath-hold Imaging 50-60 cc Non-ionic (IODINATED) contrast 20 minute procedure 15 minute interpretation
First Author Technique Patients Not evaluable Sensitivity Specificity Negative Predictive Value Leschka 64-slice CT 67 -- 94% 97% 99% Leber 64-slice CT 59 7% 73% 97% 99% Ehara 64-slice CT 69 8% 90% 94% 95% Raff 64-slice CT 70 12% 86% 95% 98% Fine 64-slice CT 66 4% 95% 96% 92% Ropers 64-slice CT 82 4% 95% 93% 99% Mollet 64-slice CT 52 2% 99% 95% 99% Nikolaou 64-slice CT 72 10% 86% 95% 97% Schlosser 64-slice CT 61 100% 95% 100% M端hlenbruc 64-slice CT 51 - 87% 95% 98% Meijboom 64-slice CT 104 - 92% 91% 99% Schuijf 64-slice CT 60 - 85% 98% 99% Oncel 64-slice CT 80 - 96% 98% 99% Herzog 64-slice CT 50 - 89% 92% 97% Ehara 64-slice CT 69 8% 90% 94% 95% Shabestari 64-slice CT 143 2% 94% 97% 97% Cademartiri 64-slice CT 72 0% 100% 98.6% 100% Hausleiter 64-slice CT 114 8% 92% 92% 99% Meijboom 64-slice CT 254 - 88% 94% 99% Andreini 64-slice CT 200 3% 99% 96% 100%
Lesion Grade Parameters % # of subjects by ICA # of subjects by CCTA 50% Sensitivity 95 49 45 Specificity 83 180 143 PPV 64 80 45 NPV 99 146 143 70% Sensitivity 94 28 26 Specificity 83 201 163 PPV 48 61 26 NPV 99 165 163 Accuracy Trial Budoff et al JACC 2008
+ CT
On to the cath lab
But NEGATIVE coronary CT angiogram
And...
A LA CASA! PHOTO BY ANDREA DAVIS
Coronary ct angiography in the er
Coronary ct angiography in the er
Coronary ct angiography in the er
Date of download: 1/4/2016 Copyright 息 The American College of Cardiology. All rights reserved. From: Coronary CT Angiography for Suspected ACS in the Era of High-Sensitivity Troponins: Randomized Multicenter Study J Am Coll Cardiol. 2016;67(1):16-26. doi:10.1016/j.jacc.2015.10.045 Length of Stay and Discharge Rate From the ED in the ACRIN-PA, ROMICAT-2, and BEACON Trials Reported data are medians. ACRIN-PA = American College of Radiology Imaging Network-Pennsylvania; BEACON = Better Evaluation of Acute Chest Pain with Computed Tomography Angiography; ROMICAT = Rule Out Myocardial Infarction using Computer Assisted Tomography; other abbreviations as in Figure 1. Figure Legend:
Coronary ct angiography in the er
State of the ART Coronary CTA Identifies normal patients 99% NPV Identify patients in need of preventative medical treatment (statin and ASA) Efficient triage for reduced down stream testing and revascularization Useful for prognosis and assessment of plaque Excellent for patients with low to intermediate risk of ACS compared to current SOC Endorsed by Peer Reviewed International Standards Groups and Insurance carriers, ESC and AHA/ACC
CAVEATS Works best for mild to moderate risk patients Avoid complex coronary anatomy, CABG, and small stents Vasculopaths High coronary calcium suspected High heart rates that cant be controlled
In Review: Proposed Chest Pain Management Very low risk chest pain; diagnose and send home Low to intermediate risk: coronary CT angiogram Moderate to high risk: nuclear stress test Very high risk: to cath lab
PROMISE Hoffman Circ 2017 The majority of events (57%, n=75/132) occurred in those with completely normal functional tests Only 8 events occurred in those with normal CCTA (5%, n=8/136) CCTA provided higher discrimination, reclassification and more robust event prediction
Coronary ct angiography in the er

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Coronary ct angiography in the er

  • 1. Coronary CT Angiography in the ER STEPHEN FLEET, M.D. CARDIOLOGY SEPTEMBER 2021
  • 3. Chest Pain Types relative to CAD Clearly atypical CP Low to intermediate probability of CAD/ACS Most probably ACS (MI or unstable angina). We are concerned with the 2nd type.
  • 4. Current Standard of Care History and Physical EKG Troponins If negative and depending on time of day, wait in ER or admit Nuclear stress test Discharge if stable
  • 7. Problems with SOC Time Consuming Costly Limited Sensitivity and Specificity
  • 9. Obstructive CAD at Cath: NCDR 2005-2007 Patel MR, Peterson ED, Dai D, Brennan JM, Redberg RF, Anderson HV, Brindis RG, Douglas PS. NEJM. 2010 Mar 11;362(10):886-95
  • 10. NEW PARADIGM WHY NOT START WITH AN ANATOMIC STUDY, WHICH CAN ACTUALLY SHOW YOU IF THERE IS SIGNIFICANT NAMELY, CORONARY CT ANGIOGRAPHY.
  • 11. ADVANTAGES READILY AVAILABLE NOW AT CHESHIRE MEDICAL CENTER TIME SAVING; MORE EFFICIENT LESS COSTLY SUPPORTED BY MULTIPLE STUDIES OVER APPROXIMATELY 15 YEARS
  • 12. METHODS - CTA 0.5-0.625 mm slices Single Breath-hold Imaging 50-60 cc Non-ionic (IODINATED) contrast 20 minute procedure 15 minute interpretation
  • 13. First Author Technique Patients Not evaluable Sensitivity Specificity Negative Predictive Value Leschka 64-slice CT 67 -- 94% 97% 99% Leber 64-slice CT 59 7% 73% 97% 99% Ehara 64-slice CT 69 8% 90% 94% 95% Raff 64-slice CT 70 12% 86% 95% 98% Fine 64-slice CT 66 4% 95% 96% 92% Ropers 64-slice CT 82 4% 95% 93% 99% Mollet 64-slice CT 52 2% 99% 95% 99% Nikolaou 64-slice CT 72 10% 86% 95% 97% Schlosser 64-slice CT 61 100% 95% 100% M端hlenbruc 64-slice CT 51 - 87% 95% 98% Meijboom 64-slice CT 104 - 92% 91% 99% Schuijf 64-slice CT 60 - 85% 98% 99% Oncel 64-slice CT 80 - 96% 98% 99% Herzog 64-slice CT 50 - 89% 92% 97% Ehara 64-slice CT 69 8% 90% 94% 95% Shabestari 64-slice CT 143 2% 94% 97% 97% Cademartiri 64-slice CT 72 0% 100% 98.6% 100% Hausleiter 64-slice CT 114 8% 92% 92% 99% Meijboom 64-slice CT 254 - 88% 94% 99% Andreini 64-slice CT 200 3% 99% 96% 100%
  • 14. Lesion Grade Parameters % # of subjects by ICA # of subjects by CCTA 50% Sensitivity 95 49 45 Specificity 83 180 143 PPV 64 80 45 NPV 99 146 143 70% Sensitivity 94 28 26 Specificity 83 201 163 PPV 48 61 26 NPV 99 165 163 Accuracy Trial Budoff et al JACC 2008
  • 15. + CT
  • 19. A LA CASA! PHOTO BY ANDREA DAVIS
  • 23. Date of download: 1/4/2016 Copyright 息 The American College of Cardiology. All rights reserved. From: Coronary CT Angiography for Suspected ACS in the Era of High-Sensitivity Troponins: Randomized Multicenter Study J Am Coll Cardiol. 2016;67(1):16-26. doi:10.1016/j.jacc.2015.10.045 Length of Stay and Discharge Rate From the ED in the ACRIN-PA, ROMICAT-2, and BEACON Trials Reported data are medians. ACRIN-PA = American College of Radiology Imaging Network-Pennsylvania; BEACON = Better Evaluation of Acute Chest Pain with Computed Tomography Angiography; ROMICAT = Rule Out Myocardial Infarction using Computer Assisted Tomography; other abbreviations as in Figure 1. Figure Legend:
  • 25. State of the ART Coronary CTA Identifies normal patients 99% NPV Identify patients in need of preventative medical treatment (statin and ASA) Efficient triage for reduced down stream testing and revascularization Useful for prognosis and assessment of plaque Excellent for patients with low to intermediate risk of ACS compared to current SOC Endorsed by Peer Reviewed International Standards Groups and Insurance carriers, ESC and AHA/ACC
  • 26. CAVEATS Works best for mild to moderate risk patients Avoid complex coronary anatomy, CABG, and small stents Vasculopaths High coronary calcium suspected High heart rates that cant be controlled
  • 27. In Review: Proposed Chest Pain Management Very low risk chest pain; diagnose and send home Low to intermediate risk: coronary CT angiogram Moderate to high risk: nuclear stress test Very high risk: to cath lab
  • 28. PROMISE Hoffman Circ 2017 The majority of events (57%, n=75/132) occurred in those with completely normal functional tests Only 8 events occurred in those with normal CCTA (5%, n=8/136) CCTA provided higher discrimination, reclassification and more robust event prediction