nach oben

Erschienen in:

01.04.2012 | Review Article

A meta-analysis and systematic review of computed tomography angiography as a diagnostic triage tool for patients with chest pain presenting to the emergency department

verfasst von: Zainab Samad, MD, Abdul Hakeem, MD, Syed Shad Mahmood, MBBS, Karen Pieper, MS, Manesh R. Patel, MD, David L. Simel, MD, MHS, Pamela S. Douglas, MD

Erschienen in: Journal of Nuclear Cardiology | Ausgabe 2/2012

Einloggen, um Zugang zu erhalten

Abstract

Background

To assess clinical utility of computed tomography angiography (CTA) in the diagnosis of chest pain patients presenting to emergency departments (EDs), we conducted a meta-analysis of CTA in patients with suspected acute coronary syndromes (ACSs).

Methods

386 studies were identified on initial review of literature. Inclusion criteria were: (1) prospective study with ≥1 month follow-up, (2) use of CTA in the ED setting, (3) use of ACC/AHA definitions for ACS and robust assessment of major adverse cardiac events, (4) ≥30 patients, and (5) study population with initial non-diagnostic ECGs and negative biomarkers.

Results

Nine studies (N = 1349) formed the data set. The pooled patient population was 52 ± 2 years of age, 51% male, with low to intermediate pretest probability for ACS. Risk factors included 12% diabetes, 42% hypertension, 35% smokers, 29% had hyperlipidemia, and 7% known CAD. ACS was subsequently diagnosed in 10% of patients. The bivariate summary estimate of sensitivity of CTA for ACS diagnosis was 95% (95% CI 88-100) and specificity was 87% (95% CI 83-92), yielding a negative likelihood ratio of 0.06 (95% CI 0-0.14) and positive likelihood ratio of 7.4 (95% CI 4.8-10). The 30-day event rate included no deaths and no additional MIs.

Conclusion

Coronary CTA demonstrates a high sensitivity and a low negative likelihood ratio of 0.06, and is effective in ruling out the presence of ACS in low to intermediate risk patients presenting to the ED with acute chest pain.

Nur mit Berechtigung zugänglich

Selker HP, Zalenski RJ, Antman EM, Aufderheide TP, Bernard SA, Bonow RO, et al. An evaluation of technologies for identifying acute cardiac ischemia in the emergency department: A report from a National Heart Attack Alert Program Working Group. Ann Emerg Med 1997;29:13-87.PubMedCrossRef

Graff LG, Dallara J, Ross MA, Joseph AJ, Itzcovitz J, Andelman RP, et al. Impact on the care of the emergency department chest pain patient from the chest pain evaluation registry (CHEPER) study. Am J Cardiol 1997;80:563-8.PubMedCrossRef

Pope JH, Aufderheide TP, Ruthazer R, Woolard RH, Feldman JA, Beshansky JR, et al. Missed diagnoses of acute cardiac ischemia in the emergency department. N Engl J Med 2000;342:1163-70.PubMedCrossRef

Amsterdam EA, Kirk JD, Diercks DB, Lewis WR, Turnipseed SD. Immediate exercise testing to evaluate low-risk patients presenting to the emergency department with chest pain. J Am Coll Cardiol 2002;40:251-6.PubMedCrossRef

Conti A, Sammicheli L, Gallini C, Costanzo EN, Antoniucci D, Barletta G. Assessment of patients with low-risk chest pain in the emergency department: Head-to-head comparison of exercise stress echocardiography and exercise myocardial SPECT. Am Heart J 2005;149:894-901.PubMedCrossRef

Sanchis J, Bodi V, Llacer A, Nunez J, Consuegra L, Bosch MJ, et al. Risk stratification of patients with acute chest pain and normal troponin concentrations. Heart 2005;91:1013-8.PubMedCrossRef

Miller JM, Rochitte CE, Dewey M, et al. Diagnostic performance of coronary angiography by 64-row CT. N Engl J Med 2008;359:2324-36.PubMedCrossRef

Stein PD, Yaekoub AY, Matta F, Sostman HD. 64-Slice CT for diagnosis of coronary artery disease: A systematic review. Am J Med 2008;121:715-25.PubMedCrossRef

Rubinshtein R, Halon DA, Gaspar T, Jaffe R, Karkabi B, Flugelman MY, et al. Usefulness of 64-slice cardiac computed tomographic angiography for diagnosing acute coronary syndromes and predicting clinical outcome in emergency department patients with chest pain of uncertain origin. Circulation 2007;115:1762-8.PubMedCrossRef

10.

Stillman AE, Oudkerk M, Ackerman M, Becker CR, Buszman PE, de Feyter PJ, et al. Use of multidetector computed tomography for the assessment of acute chest pain: A consensus statement of the North American Society of Cardiac Imaging and the European Society of Cardiac Radiology. Eur Radiol 2007;17:2196-207.PubMedCrossRef

11.

Vanhoenacker PK, Decramer I, Bladt O, Sarno G, Bevernage C, Wijns W. 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. BMC Cardiovasc Disord 2007;7:39.PubMedCrossRef

12.

Meijboom WB, Mollet NR, Van Mieghem CA, Weustink AC, Pugliese F, van Pelt N, et al. 64-Slice CT coronary angiography in patients with non-ST elevation acute coronary syndrome. Heart 2007;93:1386-92.PubMedCrossRef

13.

Olivetti L, Mazza G, Volpi D, Costa F, Ferrari O, Pirelli S. Multislice CT in emergency room management of patients with chest pain and medium-low probability of acute coronary syndrome. Radiol Med (Torino) 2006;111:1054-63.CrossRef

14.

White CS, Kuo D, Kelemen M, Jain V, Musk A, Zaidi E, et al. Chest pain evaluation in the emergency department: Can MDCT provide a comprehensive evaluation? AJR Am J Roentgenol 2005;185:533-40.PubMed

15.

Athappan G, Habib M, Ponniah T, Jeyaseelan L. Multi-detector computerized tomography angiography for evaluation of acute chest pain—a meta analysis and systematic review of literature. Int J Cardiol 2010;141:132-40.PubMedCrossRef

16.

Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE, Jr., et al. 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 (Writing Committee to Revise the 2002 Guidelines for the Management of Patients With Unstable Angina/Non ST-Elevation Myocardial Infarction): Developed in collaboration with the American College of Emergency Physicians, the Society for Cardiovascular Angiography and Interventions, and the Society of Thoracic Surgeons: Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation and the Society for Academic Emergency Medicine. Circulation 2007;116(7):e148-304.

17.

Deville WL, Buntinx F, Bouter LM, Montori VM, de Vet HC, van der Windt DA, et al. Conducting systematic reviews of diagnostic studies: Didactic guidelines. BMC Med Res Methodol 2002;2:9.PubMedCrossRef

18.

Reitsma JB, Glas AS, Rutjes AW, Scholten RJ, Bossuyt PM, Zwinderman AH. Bivariate analysis of sensitivity and specificity produces informative summary measures in diagnostic reviews. J Clin Epidemiol 2005;58:982-90.PubMedCrossRef

19.

Zwinderman AH, Bossuyt PM. We should not pool diagnostic likelihood ratios in systematic reviews. Stat Med 2008;27:687-97.PubMedCrossRef

20.

Simel DL, Bossuyt PM. Differences between univariate and bivariate models for summarizing diagnostic accuracy may not be large. J Clin Epidemiol 2009;62:1292-300.PubMedCrossRef

21.

Goldstein JA, Chinnaiyan KM, Abidov A, Achenbach S, et al. The CT-STAT (Coronary Computed Tomographic Angiography for Systematic Triage of Acute Chest Pain Patients to Treatment) trial. J Am Coll Cardiol 2011;58:1414-22.PubMedCrossRef

22.

Goldstein JA, Gallagher MJ, O’Neill WW, Ross MA, O’Neil BJ, Raff GL. A randomized controlled trial of multi-slice coronary computed tomography for evaluation of acute chest pain. J Am Coll Cardiol 2007;49:863-71.PubMedCrossRef

23.

Hollander JE, Litt HI, Chase M, Brown AM, Kim W, Baxt WG. Computed tomography coronary angiography for rapid disposition of low-risk emergency department patients with chest pain syndromes. Acad Emerg Med 2007;14:112-6.PubMedCrossRef

24.

Sato Y, Matsumoto N, Ichikawa M, Kunimasa T, Iida K, Yoda S, et al. Efficacy of multislice computed tomography for the detection of acute coronary syndrome in the emergency department. Circ J 2005;69:1047-51.PubMedCrossRef

25.

Gallagher MJ, Ross MA, Raff GL, Goldstein JA, O’Neill WW, O’Neil B. 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 2007;49:125-36.PubMedCrossRef

26.

Ueno K, Anzai T, Jinzaki M, Yamada M, Kohno T, Kawamura A, et al. Diagnostic capacity of 64-slice multidetector computed tomography for acute coronary syndrome in patients presenting with acute chest pain. Cardiology 2009;112:211-8.PubMedCrossRef

27.

Hoffmann U, Bamberg F, Chae CU, Nichols JH, Rogers IS, Seneviratne SK, et al. 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 2009;53:1642-50.PubMedCrossRef

28.

Hoffmann U, Nagurney JT, Moselewski F, Pena A, Ferencik M, Chae CU, et al. Coronary multidetector computed tomography in the assessment of patients with acute chest pain. Circulation 2006;114:2251-60.PubMedCrossRef

29.

Hoffmann U, Pena AJ, Moselewski F, Ferencik M, Abbara S, Cury RC, et al. MDCT in early triage of patients with acute chest pain. AJR Am J Roentgenol 2006;187:1240-7.PubMedCrossRef

30.

Hollander JE, Chang AM, Shofer FS, McCusker CM, Baxt WG, Litt HI. Coronary computed tomographic angiography for rapid discharge of low-risk patients with potential acute coronary syndromes. Ann Emerg Med 2009;53:295-304.PubMedCrossRef

31.

Antman EM, Cohen M, Bernink PJ, McCabe CH, Horacek T, Papuchis G, et al. The TIMI risk score for unstable angina/non-ST elevation MI: A method for prognostication and therapeutic decision making. JAMA 2000;284:835-42.PubMedCrossRef

32.

Roberts RR, Zalenski RJ, Mensah EK, Rydman RJ, Ciavarella G, Gussow L, et al. Costs of an emergency department-based accelerated diagnostic protocol vs hospitalization in patients with chest pain: A randomized controlled trial. JAMA 1997;278:1670-6.PubMedCrossRef

33.

Priest VL, Scuffham PA, Hachamovitch R, Marwick TH. Cost-effectiveness of coronary computed tomography and cardiac stress imaging in the emergency department: A decision analytic model comparing diagnostic strategies for chest pain in patients at low risk of acute coronary syndromes. JACC Cardiovasc Imaging 2011;4:549-56.PubMedCrossRef

34.

Taylor AJ, Cerqueira M, Hodgson JM, Mark D, Min J, O’Gara P, et al. ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR 2010 Appropriate Use Criteria for Cardiac Computed Tomography. A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, the Society of Cardiovascular Computed Tomography, the American College of Radiology, the American Heart Association, the American Society of Echocardiography, the American Society of Nuclear Cardiology, the North American Society for Cardiovascular Imaging, the Society for Cardiovascular Angiography and Interventions, and the Society for Cardiovascular Magnetic Resonance. J Cardiovasc Comput Tomogr 2010;4(6):407 e1-33.

35.

Burt JR, Iribarren C, Fair JM, Norton LC, Mahbouba M, Rubin GD, et al. Incidental findings on cardiac multidetector row computed tomography among healthy older adults: Prevalence and clinical correlates. Arch Intern Med 2008;168:756-61.PubMedCrossRef

36.

Hamm CW, Bassand JP, Agewall S, Bax J, Boersma E, Bueno H, et al. ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The Task Force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the European Society of Cardiology (ESC). Eur Heart J 2011;32(23):2999-3054.

37.

NICE Clinical Guideline. Chest pain of recent onset: Assessment and diagnosis of recent onset chest pain or discomfort of suspected cardiac origin. London: NICE Clinical Guideline; 2010.

38.

Simel DL, Samsa GP, Matchar DB. Likelihood ratios with confidence: Sample size estimation for diagnostic test studies. J Clin Epidemiol 1991;44:763-70.PubMedCrossRef

Titel: A meta-analysis and systematic review of computed tomography angiography as a diagnostic triage tool for patients with chest pain presenting to the emergency department
verfasst von: Zainab Samad, MD
Abdul Hakeem, MD
Syed Shad Mahmood, MBBS
Karen Pieper, MS
Manesh R. Patel, MD
David L. Simel, MD, MHS
Pamela S. Douglas, MD
Publikationsdatum: 01.04.2012
Verlag: Springer-Verlag
Erschienen in: Journal of Nuclear Cardiology / Ausgabe 2/2012
Print ISSN: 1071-3581
Elektronische ISSN: 1532-6551
DOI: https://doi.org/10.1007/s12350-012-9520-2

Update Kardiologie

Bestellen Sie unseren Fach-Newsletter und bleiben Sie gut informiert.

Newsletter bestellen

Die Highlights vom Kongress des American College of Cardiology 2024

Springer Medizin

A meta-analysis and systematic review of computed tomography angiography as a diagnostic triage tool for patients with chest pain presenting to the emergency department