Coronary Computed Tomography Angiography for Early Triage of Patients With Acute Chest Pain: The ROMICAT (Rule Out Myocardial Infarction using Computer Assisted Tomography) Trial
This study was designed to determine the usefulness of coronary computed tomography angiography (CTA) in patients with acute chest pain.
Background
Triage of chest pain patients in the emergency department remains challenging.
Methods
We used an observational cohort study in chest pain patients with normal initial troponin and nonischemic electrocardiogram. A 64-slice coronary CTA was performed before admission to detect coronary plaque and stenosis (>50% luminal narrowing). Results were not disclosed. End points were acute coronary syndrome (ACS) during index hospitalization and major adverse cardiac events during 6-month follow-up.
Results
Among 368 patients (mean age 53 ± 12 years, 61% men), 31 had ACS (8%). By coronary CTA, 50% of these patients were free of coronary artery disease (CAD), 31% had nonobstructive disease, and 19% had inconclusive or positive computed tomography for significant stenosis. Sensitivity and negative predictive value for ACS were 100% (n = 183 of 368; 95% confidence interval [CI]: 98% to 100%) and 100% (95% CI: 89% to 100%), respectively, with the absence of CAD and 77% (95% CI: 59% to 90%) and 98% (n = 300 of 368, 95% CI: 95% to 99%), respectively, with significant stenosis by coronary CTA. Specificity of presence of plaque and stenosis for ACS were 54% (95% CI: 49% to 60%) and 87% (95% CI: 83% to 90%), respectively. Only 1 ACS occurred in the absence of calcified plaque. Both the extent of coronary plaque and presence of stenosis predicted ACS independently and incrementally to Thrombolysis In Myocardial Infarction risk score (area under curve: 0.88, 0.82, vs. 0.63, respectively; all p < 0.0001).
Conclusions
Fifty percent of patients with acute chest pain and low to intermediate likelihood of ACS were free of CAD by computed tomography and had no ACS. Given the large number of such patients, early coronary CTA may significantly improve patient management in the emergency department.
Key Words
cardiac CT
emergency department
acute chest pain
Abbreviations and Acronyms
ACS
acute coronary syndrome
AUC
area under the receiver-operating characteristics curve
CAD
coronary artery disease
CI
confidence interval
CT
computed tomography
CTA
computed tomography angiography
ECG
electrocardiogram
ED
emergency department
MACE
major adverse cardiac event(s)
MI
myocardial infarction
NPV
negative predictive value
OR
odds ratio
PPV
positive predictive value
SPECT
single-positron emission computed tomography
TIMI
Thrombolysis In Myocardial Infarction
UAP
unstable angina pectoris
Cited by (0)
This work was supported by the National Institutes of Health (R01 HL080053) and in part supported by Siemens Medical Solutions and GE Healthcare. Drs. Rogers, Truong, Shapiro, and Moloo were supported by the National Institutes of Health grant T32HL076136. Dr. Hoffmann has received research grants from GE Healthcare and Siemens. Dr. Abbara has received research funding from Bracco and consulting honoraria (minor) from Ezem, Siemens, Partners Imaging, Magellan Health, Perceptive Informatics. Dr. Achenbach has received grant support from Siemens and Bayer Schering Pharma. Dr. Nagurney is funded by Biosite for a biomarker research study.
