Detection of non-ST-elevation myocardial infarction and unstable angina in the acute setting: meta-analysis of diagnostic performance of multi-detector computed tomographic angiography

Piet K Vanhoenacker, Isabel Decramer, Olivier Bladt, Giovanna Sarno, Charlotte Bevernage, William Wijns, Piet K Vanhoenacker, Isabel Decramer, Olivier Bladt, Giovanna Sarno, Charlotte Bevernage, William Wijns

Abstract

Background: Multi-detector computed tomography angiography (MDCTA) has been increasingly used in the evaluation of the coronary arteries. The purpose of this study was to review the literature on the diagnostic performance of MDCTA in the acute setting, for the detection of non-ST-elevation myocardial infarction (NSTEMI) and unstable angina pectoris (UAP).

Methods: A Pubmed and manual search of the literature published between January 2000 and June 2007 was performed. Studies were included that compared MDCTA with clinical outcome and/or CA in patients with acute chest pain, presenting at the emergency department. More specifically, studies that only included patients with initially negative cardiac enzymes suspected of having NSTEMI or UAP were included. Summary estimates of diagnostic odds ratio (DOR), sensitivity and specificity, negative (NLR) and positive likelihood ratio (PLR) were calculated on a patient basis. Random-effects models and summary receiver operating curve (SROC) analysis were used to assess the diagnostic performance of MDCTA with 4 detectors or more. The proportion of non assessable scans (NAP) on MDCTA was also evaluated. In addition, the influence of study characteristics of each study on diagnostic performance and NAP was investigated with multivariable logistic regression.

Results: Nine studies totalling 566 patients, were included in the meta-analysis: one randomised trial and eight prospective cohort studies. Five studies on 64-detector MDCTA and 4 studies on MDCTA with less than 64 detectors were included (32 detectors n = 1, 16 detectors n = 2, 16 and 4 detectors n = 1). Pooled DOR was 131.81 (95%CI, 50.90-341.31). The pooled sensitivity and specificity were 0.95 (95%CI, 0.90-0.98) and 0.90 (95%CI, 0.87-0.93). The pooled NLR and PLR were 0.12 (95%CI, 0.06-0.21) and 8,60 (95%CI, 5.03-14,69).The results of the logistic regressions showed that none of the investigated variables had influence on the diagnostic performance or NAP CONCLUSION: MDCTA of the coronary arteries performs good to excellent in the diagnosis of coronary artery disease in the acute setting and it can be used for early exclusion of NSTEMI or UAP in patients in the emergency department.

Figures

Figure 1
Figure 1
Flow diagram of the reviewing process.
Figure 2
Figure 2
Flowdiagram of patient inclusion with patient categories used in summarizing data. In the studies analysed, from the eligible patients only a part was enrolled in the studies. The patients that were finally included was the subset of enrolled patients that completed the full protocol and that had diagnostic scans. Non assessable proportion (NAP) was the ratio of non-diagnostic patients or technical failures to the finally included patient.
Figure 3
Figure 3
Graphical representation of publication bias. The dots, each representing one study are conforming to a triangular form, meaning that publication bias is low.
Figure 4
Figure 4
Forest plot of sensitivity on a per patient basis.
Figure 5
Figure 5
Forest plot of specificity on a per patient basis.
Figure 6
Figure 6
Forest plot of positive likelihood ratio on a per patient basis. LR: Likelihood ratio.
Figure 7
Figure 7
Forest plot of negative likelihood ratio on a per patient basis. LR: Likelihood ratio.
Figure 8
Figure 8
Forest plot of diagnostic odds ratio on a per patient basis. OR: Odds ratio.
Figure 9
Figure 9
SROC curve of per patient analysis. AUC: Area under the curve. SE: Standard error. Q*: Point of intersection of the SROC curve where SE and SP are equal.

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