hs-Troponin I Followed by CT Angiography Improves Acute Coronary Syndrome Risk Stratification Accuracy and Work-Up in Acute Chest Pain Patients: Results From ROMICAT II Trial

doi:10.1016/j.jcmg.2015.06.016

JACC: Cardiovascular Imaging

Volume 8, Issue 11, November 2015, Pages 1272-1281

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Abstract

Objectives

This study compared diagnostic accuracy of conventional troponin/traditional coronary artery disease (CAD) assessment and highly sensitive troponin (hsTn) I/advanced CAD assessment for acute coronary syndrome (ACS) during the index hospitalization.

Background

hsTnI and advanced assessment of CAD using coronary computed tomography angiography (CTA) are promising candidates to improve the accuracy of emergency department evaluation of patients with suspected ACS.

Methods

We performed an observational cohort study in patients with suspected ACS enrolled in the ROMICAT II (Rule Out Myocardial Infarction/Ischemia using Computer Assisted Tomography) trial and randomized to coronary CTA who also had hsTnI measurement at the time of the emergency department presentation. We assessed coronary CTA for traditional (no CAD, nonobstructive CAD, ≥50% stenosis) and advanced features of CAD (≥50% stenosis, high-risk plaque features: positive remodeling, low <30-Hounsfield units plaque, napkin-ring sign, spotty calcium).

Results

Of 160 patients (mean age: 53 ± 8 years, 40% women) 10.6% were diagnosed with ACS. The ACS rate in patients with hsTnI below the limit of detection (n = 9, 5.6%), intermediate (n = 139, 86.9%), and above the 99th percentile (n = 12, 7.5%) was 0%, 8.6%, and 58.3%, respectively. Absence of ≥50% stenosis and high-risk plaque ruled out ACS in patients with intermediate hsTnI (n = 87, 54.4%; ACS rate 0%), whereas patients with both ≥50% stenosis and high-risk plaque were at high risk (n = 13, 8.1%; ACS rate 69.2%) and patients with either ≥50% stenosis or high-risk plaque were at intermediate risk for ACS (n = 39, 24.4%; ACS rate 7.7%). hsTnI/advanced coronary CTA assessment significantly improved the diagnostic accuracy for ACS as compared to conventional troponin/traditional coronary CTA (area under the curve 0.84, 95% confidence interval [CI]: 0.80 to .88 vs. 0.74, 95% CI: 0.70 to 0.78; p < 0.001).

Conclusions

hsTnI at the time of presentation followed by early advanced coronary CTA assessment improves the risk stratification and diagnostic accuracy for ACS as compared to conventional troponin and traditional coronary CTA assessment. (Multicenter Study to Rule Out Myocardial Infarction/Ischemia by Cardiac Computed Tomography [ROMICAT-II]; NCT01084239)

Key Words

acute coronary syndrome

coronary computed tomography angiography

coronary plaque

emergency department

highly sensitive troponin

risk stratification

Abbreviations and Acronyms

ACS

acute coronary syndrome

AUC

area under the receiver operating characteristics curve

CAD

coronary artery disease

confidence interval

CTA

computed tomography angiography

emergency department

hsTn

highly sensitive troponin

Hounsfield units

LOD

limit of detection

NPV

negative predictive value

PPV

positive predictive value

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: The ROMICAT II trial is supported by the National Institutes of Health grant numbers NIH U01HL092040 and U01HL092022, ACRIN. The content of this paper is solely the responsibility of the authors and does not necessarily reflect the views of the National Institutes of Health or the Department of Health and Human Services. Dr. Ferencik has received a research grant from the American Heart Association Fellow to Faculty Award 13FTF16450001. Dr. Truong has received research grants from NIH/NHLBI K23HL098370 and L30HL093896, St. Jude Medical, American College of Radiology Imaging Network, and Duke Clinical Research. Dr. Peacock has received research grants from Abbott, Alere, Banyan, Cardiorentis, Portola, Roche, and The Medicines Company; has ownership of Comprehensive Research Associates LLC and Emergencies in Medicine LLC; is a consultant with and on advisory boards for BG Medicine, Beckman, Boehringer-Ingelheim, Instrument Labs, Prevencio, The Medicines Company, ZS Pharma, Alere, Cardiorentis, and Janssen. Dr. Nagurney has received research grants from Alere/Biosite, Brahms Ltd/Thermo-Fisher, Nanosphere; is a consultant for and on advisory board at CardioDx. Dr. Januzzi received research grants from Siemens, Thermo Fisher, and Singulex; is a consultant with and on advisory board of Critical Diagnostics, Sphingotec, and Roche. Dr. Hoffmann received research grants from NIH U01HL092040, U01HL092022, Siemens Medical Solutions, Heart Flow Inc.; and is a consultant for and on advisory board of Heart Flow. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. Drs. Ferencik and Liu contributed equally to this work.