Diagnostic accuracy and clinical outcomes of ECG-gated, whole chest CT in the emergency department

Kelley R Branch, Jared Strote, William P Shuman, Lee M Mitsumori, Janet M Busey, Tessa Rue, James H Caldwell, Kelley R Branch, Jared Strote, William P Shuman, Lee M Mitsumori, Janet M Busey, Tessa Rue, James H Caldwell

Abstract

Purpose: The purpose of this study was to assess the diagnostic accuracy and one year prognosis of whole chest, "multiple rule out" CT for coronary artery disease (CAD) in Emergency Department patients.

Methods and findings: One hundred and two Emergency Department patients at low to intermediate risk of acute coronary syndrome (ACS), pulmonary embolism and/or acute aortic syndrome underwent a research 64 channel ECG-gated, whole chest CT and a standard of care evaluation. Patients were classified with obstructive CAD with either a coronary CT stenosis greater than 50% or a non-evaluable coronary segment. SOC and 3 month follow up data were used to determine an adjudicated clinical diagnosis. The diagnostic ability of obstructive CAD on CT to identify clinical diagnoses was determined. Patients were followed up for 1 year for cardiac events. Seven (7%) patients were diagnosed with ACS. CT sensitivity to detect obstructive CAD in ACS patients was 100% (95% CI 65%, 100%), negative predictive value 100% (96%, 100%), specificity 88% (80%, 94%), and positive predictive value 39% (17%, 64%). Pulmonary embolism and acute aortic syndrome were not identified in any patients. No cardiac events occurred in patients without obstructive CAD over 1 year.

Conclusions: Whole chest CT has high sensitivity and negative predictive value for ACS with excellent one year prognosis in patients without obstructive CAD on CT. The frequency of pulmonary embolism or acute aortic syndrome and the higher radiation dose suggest whole chest CT should be limited to select patients. ClinicalTrials.org #: NCT00855231.

Conflict of interest statement

Competing Interests: The authors have the following interests. A GE Healthcare research grant supports 1) Ms. Busey’s University of Washington salary and, to a far lesser extent, Dr.’s Shuman and Branch University salaries, and 2) the cost of many of the research CT scans. This does not alter the authors’ adherence to all the PLOS ONE policies on sharing data and materials, as detailed online in the guide for authors.

Figures

Figure 1. Clinical trial protocol and patient…
Figure 1. Clinical trial protocol and patient evaluation flowchart. ACS = acute coronary syndrome, CAD = coronary artery disease, CT = computed tomography.
Figure 2. Patient enrollment and 3 month…
Figure 2. Patient enrollment and 3 month outcomes. CABG = coronary artery bypass grafting, CAD = coronary artery disease, IV = intravenous, MI = myocardial infarction, PCI = percutaneous coronary intervention.
Figure 3. Empiric ROC curve for ordinal…
Figure 3. Empiric ROC curve for ordinal coronary CT stenosis quintiles compared to the adjudicated diagnosis of ACS. AUC = area under the curve.
Figure 4. Patient-level diagnostic measures of CT…
Figure 4. Patient-level diagnostic measures of CT by clinical pre-test probability of ACS (A) and by TIMI Risk Score (B).
The pre-test probability of ACS (A) was determined by the clinical judgment of the ED physician caring for the patient. NPV = negative predictive value; PPV = positive predictive value.

References

    1. Brown JE, Hamilton GC (2002) Chest Pain. In: Marx JA, Hockberger RS, Walls RM, editors. Rosen’s Emergency Medicine: Concepts and Clinical Practice. St. Louis: Mosby. 162–172.
    1. Pope JH, Aufderheide TP, Ruthazer R, Woolard RH, Feldman JA, et al. (2000) Missed Diagnoses of Acute Cardiac Ischemia in the Emergency Department. N Engl J Med 342: 1163–1170.
    1. Dalen JE, Alpert JS (1975) Natural history of pulmonary embolism. Prog Cardiovasc Dis 17: 259–270.
    1. Hamon M, Biondi-Zoccai GG, Malagutti P, Agostoni P, Morello R, et al. (2006) Diagnostic performance of multislice spiral computed tomography of coronary arteries as compared with conventional invasive coronary angiography: a meta-analysis. J Am Coll Cardiol 48: 1896–1910.
    1. Hoffmann U, Bamberg F, Chae CU, Nichols JH, Rogers IS, et al. (2009) Coronary computed tomography angiography for early triage of patients with acute chest pain: The ROMICAT (Rule Out Myocardial Infarction using Computer Assisted Tomography) Trial. J Am Coll Cardiol 53: 1642–1650.
    1. Ladapo JA, Jaffer FA, Hoffmann U, Thomson CC, Bamberg F, et al. (2009) Clinical outcomes and cost-effectiveness of coronary computed tomography angiography in the evaluation of patients with chest pain. J Am Coll Cardiol 54: 2409–2422.
    1. May JM, Shuman WP, Strote JN, Branch KR, Mitsumori LM, et al. (2009) Low-risk patients with chest pain in the emergency department: negative 64-MDCT coronary angiography may reduce length of stay and hospital charges. AJR Am J Roentgenol 193: 150–154.
    1. Branch KR, Bresnahan BW, Veenstra DL, Shuman WP, Weintraub WS, et al. (2012) Economic outcome of cardiac CT-based evaluation and standard of care for suspected acute coronary syndrome in the emergency department: a decision analytic model. Acad Radiol 19: 265–273.
    1. Johnson TRC, Nikolaou K, Wintersperger BJ, Knez A, Boekstegers P, et al. (2007) ECG-Gated 64-MDCT angiography in the differential diagnosis of acute chest pain. Am J Roentgenol 188: 76–82.
    1. Savino G, Herzog C, Costello P, Schoepf UJ (2006) 64 slice cardiovascular CT in the Emergency Department: concepts and first experiences. Radiol Med: 481–496.
    1. Takakuwa KM, Halpern EJ (2008) Evaluation of a “triple rule-out” coronary CT angiography protocol: Use of 64-section CT in low-to-moderate risk Emergency Department patients suspected of having acute coronary syndrome. Radiology 248: 438–446.
    1. Rubinshtein R, Halon DA, Gaspar T, Jaffe R, Goldstein J, et al. (2007) Impact of 64-slice cardiac computed tomographic angiography on clinical decision-making in emergency department patients with chest pain of possible myocardial ischemic origin. Am J Cardiol 100: 1522–1526.
    1. Shuman WP, May JM, Branch KR, Mitsumori LM, Strote JN, et al. (2010) Negative ECG-gated cardiac CT in patients with low-to-moderate risk chest pain in the emergency department: 1-year follow-up. Am J Roentgenol 195: 923–927.
    1. Lee HY, Yoo SM, White CS (2009) Coronary CT angiography in emergency department patients with acute chest pain: triple rule-out protocol versus dedicated coronary CT angiography. Int J Cardiovasc Imaging 25: 319–326.
    1. Shapiro MD (2009) Is the “triple rule-out” study an appropriate indication for cardiovascular CT? J Cardiovasc Comput Tomogr 3: 100–103.
    1. AAPM Task Group 23 of the Diagnostic Imaging Council CT Committee. The Measurement, Reporting, and Management of Radiation Dose in CT [AAPM Report 96]. College Park, MD: American Association of Physicists in Medicine, January 2008. Available at ; accessed April 15, 2010.
    1. Sebastia C, Pallisa E, Quiroga S, Alvarez-Castells A, Dominguez R, et al. (1999) Aortic Dissection: Diagnosis and Follow-up with Helical CT. Radiographics 19: 45–60.
    1. Mullins MD, Becker DM, Hagspiel KD, Philbrick JT (2000) The role of spiral volumetric computed tomography in the diagnosis of pulmonary embolism. Arch Intern Med 160: 293–298.
    1. Wittram C (2007) How I Do It: CT Pulmonary Angiography. Am J Roentgenol 188: 1255–1261.
    1. Shuman WP, Branch KR, May JM, Mitsumori LM, Lockhart DW, et al. (2008) Prospective versus retrospective ECG gating for 64-detector CT of the coronary arteries: Comparison of image quality and patient radiation dose. Radiology 248: 431–437.
    1. Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, et al. (2007) ACC/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non-ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 50: e1–157.
    1. Cerqueira MD, Weissman NJ, Dilsizian V, Jacobs AK, Kaul S, et al... (2002) Standardized myocardial segmentation and nomenclature for tomographic imaging of the heart. A statement for healthcare professionals from the cardiac imaging committee of the council on clinical cardiology of the American Heart Association. Circulation: 539–542.
    1. Pellikka PA, Nagueh SF, Elhendy AA, Kuehl CA, Sawada SG (2007) American Society of Echocardiography recommendations for performance, interpretation, and application of stress echocardiography. J Am Soc Echocardiogr 20: 1021–1041.
    1. White CS, Kuo D, Kelemen M, Jain V, Musk A, et al. (2005) Chest pain evaluation in the emergency department: Can MDCT provide a comprehensive evaluation? Am J Roentgenol 185: 533–540.
    1. Madder RD, Raff GL, Hickman L, Foster NJ, McMurray MD, et al. (2011) Comparative diagnostic yield and 3-month outcomes of “triple rule-out” and standard protocol coronary CT angiography in the evaluation of acute chest pain. J Cardiovasc Comput Tomogr 5: 165–171.
    1. Chang S-A, Choi SI, Choi E-K, Kim H-K, Jung J-W, et al. (2008) Usefulness of 64-slice multidetector computed tomography as an initial diagnostic approach in patients with acute chest pain. American Heart Journal 156: 375–383.
    1. Gallagher MJ, Ross MA, Raff GL, Goldstein JA, O’Neill WW, et al. (2007) The diagnostic accuracy of 64-slice computed tomography coronary angiography compared with stress nuclear imaging in emergency department low-risk chest pain patients. Ann Emerg Med 49: 125–136.
    1. Meijboom WB, Mollet NR, Van Mieghem CA, Weustink AC, Pugliese F, et al. (2007) 64-Slice CT coronary angiography in patients with non-ST elevation acute coronary syndrome. Heart 93: 1386–1392.
    1. Rahmani N, Jeudy J, White CS (2009) Triple rule-out and dedicated coronary artery CTA: Comparison of coronary artery image quality. Acad Radiol 16: 604–609.
    1. Halpern EJ, Levin DC, Zhang S, Takakuwa KM (2009) Comparison of image quality and arterial enhancement with a dedicated coronary CTA protocol versus a Triple Rule-Out coronary CTA protocol. Acad Radiol 16: 1039–1048.
    1. Earls JP, Berman EL, Urban BA, Curry CA, Lane JL, et al. (2008) Prospectively gated transverse coronary CT angiography versus retrospectively gated helical technique: Improved image quality and reduced radiation dose. Radiology 246: 742–753.
    1. DeFrance T, Dubois E, Gebow D, Ramirez A, Wolf F, et al. (2010) Helical prospective ECG-gating in cardiac computed tomography: radiation dose and image quality. Int J Cardiovasc Imaging 26: 99–107.
    1. Hirai N, Horiguchi J, Fujioka C, Kiguchi M, Yamamoto H, et al. (2008) Prospective versus retrospective ECG-gated 64-detector coronary CT angiography: Assessment of image quality, stenosis, and radiation dose. Radiology 248: 424–430.
    1. Branch KR, Busey JM, Mitsumori LM, Strote J, Caldwell JH, et al... (2013) Diagnostic performance of resting CT myocardial perfusion in patients with possible acute coronary syndrome. Am J Roentgenol In Press.
    1. LaBounty TM, Earls JP, Leipsic J, Heilbron B, Mancini GB, et al. (2010) Effect of a standardized quality-improvement protocol on radiation dose in coronary computed tomographic angiography. Am J Cardiol 106: 1663–1667.
    1. Earls JP, Leipsic J (2010) Cardiac computed tomography technology and dose-reduction strategies. Radiol Clin North Am 48: 657–674.
    1. Krissak R, Henzler T, Prechel A, Reichert M, Gruettner J, et al. Triple-rule-out dual-source CT angiography of patients with acute chest pain: Dose reduction potential of 100kV scanning. Eur J Radiol.
    1. Durmus T, Rogalla P, Lembcke A, Muhler MR, Hamm B, et al. Low-dose triple-rule-out using 320-row-detector volume MDCT–less contrast medium and lower radiation exposure. Eur Radiol 21: 1416–1423.
    1. Einstein AJ, Henzlova MJ, Rajagopalan S (2007) Estimating risk of cancer associated with radiation exposure from 64-slice computed tomography coronary angiography. JAMA 298: 317–323.
    1. Schertler T, Frauenfelder T, Stolzmann P, Scheffel H, Desbiolles L, et al. (2009) Triple Rule-Out CT in patients with suspicion of acute pulmonary embolism: Findings and accuracy. Acad Radiol 16: 708–717.

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