Coronary artery disease
A Computed Tomography-Based Coronary Lesion Score to Predict Acute Coronary Syndrome Among Patients With Acute Chest Pain and Significant Coronary Stenosis on Coronary Computed Tomographic Angiogram

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We tested the hypothesis that morphologic lesion assessment helps detect acute coronary syndrome (ACS) during index hospitalization in patients with acute chest pain and significant stenosis on coronary computed tomographic angiogram (CTA). Patients who presented to an emergency department with chest pain but no objective signs of myocardial ischemia (nondiagnostic electrocardiogram and negative initial biomarkers) underwent CT angiography. CTA was analyzed for degree and length of stenosis, plaque area and volume, remodeling index, CT attenuation of plaque, and spotty calcium in all patients with significant stenosis (>50% in diameter) on CTA. ACS during index hospitalization was determined by a panel of 2 physicians blinded to results of CT angiography. For lesion characteristics associated with ACS, we determined cutpoints optimized for diagnostic accuracy and created lesion scores. For each score, we determined the odds ratio (OR) and discriminatory capacity for the prediction of ACS. Of the overall population of 368 patients, 34 had significant stenosis and 21 of those had ACS. Scores A (remodeling index plus spotty calcium: OR 3.5, 95% confidence interval [CI] 1.2 to 10.1, area under curve [AUC] 0.734), B (remodeling index plus spotty calcium plus stenosis length: OR 4.6, 95% CI 1.6 to 13.7, AUC 0.824), and C (remodeling index plus spotty calcium plus stenosis length plus plaque volume <90 HU: OR 3.4, 95% CI 1.5 to 7.9, AUC 0.833) were significantly associated with ACS. In conclusion, in patients presenting with acute chest pain and stenosis on coronary CTA, a CT-based score incorporating morphologic characteristics of coronary lesions had a good discriminatory value for detection of ACS during index hospitalization.

Section snippets

Methods

A description of the patient population in the present study was reported recently.6 A convenience sample of low- to intermediate-risk patients presenting to an emergency department with a chief complaint of chest discomfort and clinical suspicion for ACS but who had normal initial troponin and an initial electrocardiogram without evidence of myocardial ischemia was enrolled. ACS was defined as acute myocardial infarction or unstable angina pectoris during index hospitalization according to

Results

The mean age of the entire Rule Out Myocardial Infarction using Computer Assisted Tomography (ROMICAT) trial population was 53 ± 12 years old; 223 (61%) were men. Of the overall study population, 31 (8%) were judged to have ACS. Overall, 34 of 368 patients (9%) had definite coronary stenosis (>50% in diameter) by coronary CT angiography. Of those 62% (21 of 34) had ACS (acute myocardial infarction, n = 5; unstable angina pectoris, n = 16). In the group of patients with ACS, 13 patients

Discussion

We demonstrated that various CT-based morphologic features of plaque (positive remodeling, spotty calcium, stenosis length, low attenuation plaque volume) were associated with presence of ACS in patients with acute chest pain and significant coronary stenosis on CTA but without objective signs of myocardial ischemia or necrosis at time of CT examination before hospital admission. We established cutpoints for 2 new quantitative measurements: lesion length (4.5 mm) and volume of low attenuation

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This work was supported by Grant RO1 HL080053 from the National Institutes of Health, Bethesda, Maryland and supported in part by Siemens Medical Solutions, Forchheim, Germany and General Electric Healthcare, Princeton, New Jersey. Dr. Ferencik, Dr. Rogers, Dr. Truong, and Dr. Ghoshhajra were supported by Grant T32 HL076136 from the National Institutes of Health. Dr. Hoffmann has received research grants from Siemens Medical Solutions and General Electric Healthcare. Dr. Nagurney is funded by Biosite, San Diego, California for a biomarker research study.

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