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Coronary CT Angiography in NSTEACS Patients
Study Questions:
What is the accuracy of coronary computed tomography angiography (CCTA) to identify coronary artery disease (CAD) in patients with non–ST-segment elevation acute coronary syndrome (NSTEACS)?
Methods:
This study randomized patients with NSTEACS to either very early (<12 hour) or standard (48- to 72-hour) invasive coronary angiography (ICA). As part of an observational component of the trial, patients had CCTA when technically feasible, and the results of the CCTA remained blinded. The accuracy of CCTA to identify CAD with a stenosis ≥50% was compared to ICA.
Results:
A total of 2,147 patients were randomized in the study, with CCTA performed in 1,023 subjects: 67.2% were male and the mean age was 61.9 ± 11.9 years. An elevated troponin was present in 77.9% of individuals, and new electrocardiographic changes were seen in 40.4% of patients. By ICA, a stenosis ≥50% was observed in 67.4% of subjects. The overall sensitivity, specificity, positive predictive value, and negative predictive value for CCTA were 96.5%, 72.4%, 87.9%, and 90.9%, respectively. In a subgroup of patients with diagnostic studies, CCTA sensitivity and specificity were 96.3% and 76.0%; a subgroup without history of CAD had sensitivity and specificity of 96.4% and 76.6%.
Conclusions:
This study finds that CCTA has high diagnostic accuracy to exclude significant CAD among individuals with NSTEACS.
Perspective:
This study observes high sensitivity and negative predictive value for CCTA in patients with NSTEACS. The specificity was lower, although it improved with either exclusion of patients with nondiagnostic studies or known CAD. The findings suggest that CCTA could be helpful to exclude significant CAD in NSTEACS, and a negative CCTA could reduce the need for ICA. However, over two thirds of individuals in this study had significant CAD on ICA. In clinical practice, a large number of these individuals would undergo both CCTA and ICA, increasing exposure to both iodinated contrast and ionizing radiation. A more effective clinic role for CCTA may be in patients with a lower likelihood of significant CAD, where a majority of patients could have CCTA alone without need for ICA.
Clinical Topics: Acute Coronary Syndromes, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Atherosclerotic Disease (CAD/PAD), Interventions and ACS, Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Computed Tomography, Nuclear Imaging
Keywords: Acute Coronary Syndrome, Cardiology Interventions, Coronary Angiography, Constriction, Pathologic, Coronary Artery Disease, Diagnostic Imaging, Electrocardiography, Radiation, Ionizing, Tomography, X-Ray Computed, Troponin
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