Emerging roles of MSCT for patient with acute chest pain - Nguyễn Xuân Trình

Emerging Roles of MSCT for Patient with 
Acute Chest Pain 
Bs CK II. Nguyễn Xuân Trình 
Bs Phan Thanh Hải 
Department of Cardiology 
 MEDIC Medical Center 
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Acute Chest Pain(ACP) And the ED 
2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent 
ST-segment elevation 
• 5–10% STEMI 
• 15–20% NSTEMI 
• 10% unstable angina 
• 15% other cardiac conditions 
• 50% non-cardiac diseases. 
• Several cardiac and non-cardiac conditions may mimic NSTE-ACS 
• Differential diagnosis of NSTE-ACS: 
• Aortic dissection, 
• Pulmonary embolism. 
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Acute Coronary Syndrome and the ED 
• 8-10 million ED chest pain presentations/ yr in US 
• 85-95% have a final diagnosis other than MI or UA 
• Unnecessary admissions (60-80%) and testing to exclude ACS 
• But, big downside for missed diagnosis (up to 5%) 
• General agreement in USA, <1% miss rate is needed 
• Clinical exam, risk factors, and markers can’t do it 
 Harold Litt. Available online at www.nasci.org 
Udo Hoffmann . Circ Cardiovasc Imaging. 2009;2:251-263. 
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Goals for ED ACP Evaluation 
• Exclude or diagnose causes with morbidity if untreated 
• Discharge safely if negative - Sens, NPV. 
 Goal is <1% 30-day event rate 
• Provide good “warranty period” for negative evaluation 
• Provide risk assessment for outpatient treatment 
• Do it efficiently and as cheaply as possible 
Harold Litt. Available online at www.nasci.org 
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Coro CTA in Acute Chest Pain and ED 
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Cardiac MSCT as the Solution 
• Single center trials (some large): 
 - CT is safe (<1% 30-day event rate ) 
 - CT is efficient (8-12 hrs vs. 24 hrs usual care) 
 - CT costs less ($250 - $2500 savings per pt) 
 - CT reduces repeat ED visits and readmissions 
• Multicenter trials: 
– CT-STAT 
– ACRIN PA 4005 and ROMICAT II 
– Why does CT work? It acts as a surrogate for cath. 
– ED physicians and patients believe the results 
Harold Litt. Available online at www.nasci.org 
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• No 30-day MACE in 640 pts with Neg CCTA 
– 0% event rate, 95% CI 0–0.57% 
• Discharged from ED: 50% ( CCTA) vs. 23% (95% CI 21.4-33.2) 
• LOS shorter: 
 – Overall CCTA vs. traditional care: 18 vs. 25 hrs, p < 0.001 
 – Negative testing: 12 vs. 25 hrs, p < 0.001 
Harold I. Litt et al. N Engl J Med 2012;366:1393-403. 
ACRIN PA 4005 
 (American College of Radiology Imaging Network / Pennsylvania Department of Health) 
Multicenter randomized, controlled Trial 
N=1,370 patients 
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Endpoints CCTA 
(n=501) 
Standard 
Evaluation 
(n=499) 
P- Value 
Length of hospital stay (hrs) 23. 2 ± 37 30.8 ± 28 0.0002 
 Missed ACS /72h 0% 0% 
 28-day MACE (Safety) 0.4% 1.0% 0.37 
Direct ED discharge (Efficiency) 47% 12% 0.001 
Time to Diagnosis in hours 10.4 ± 12.6 18.7 ± 11.8 0.0001 
ED Costs of care 2053 2532 < 0.0001 
ROMICAT II 
Udo Hoffmann et al. N Engl J Med. 2012 Jul 26; 367(4): 299–308. 
• N = 1000 pts low-intermediate risk patients 
• CCTA (n=501) vs Standard Evaluation(n= 499) 
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J Am Coll Cardiol. 2016;67(1):16-26. 
The BEACON (Better Evaluation of Acute Chest Pain with 
Computed Tomography Angiography), n= 500 pts 
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Coronary CT Angiography for Suspected ACS 
The BEACON (Better Evaluation of Acute Chest Pain with 
Computed Tomography Angiography), n= 500 pts 
J Am Coll Cardiol. 2016;67(1):16-26. 
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Coronary CT Angiography for Suspected ACS 
The BEACON (Better Evaluation of Acute Chest Pain with 
Computed Tomography Angiography), n= 500 pts 
J Am Coll Cardiol. 2016;67(1):16-26. 
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Smulders et al. Am Heart J. July 2016; Vol. 177:102-11 
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Smulders et al. Am Heart J. July 2016; Vol. 177:102-11 
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Rybicki et al . Appropriate Utilization of Cardiovascular Imaging in Emergency 
Department Patients With Chest Pain. J Am Coll Radiol 2016;13:e1-e29 
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Rybicki et al . Appropriate Utilization of Cardiovascular Imaging in Emergency Department Patients With Chest Pain. J Am Coll Radiol 2016;13:e1-e29 
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Imaging of Patients for Whom the Initial Workup Is Diagnostic for STEMI or Noncardiac 
Rybicki et al . Appropriate Utilization of Cardiovascular Imaging in Emergency 
Department Patients With Chest Pain. J Am Coll Radiol 2016;13:e1-e29 
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Suspected Non–ST-Segment Elevation ACS: 
Early Assessment Pathway Based on Initial ECG, Biomarker Analysis, and Symptoms 
Rybicki et al . Appropriate Utilization of Cardiovascular Imaging in Emergency 
Department Patients With Chest Pain. J Am Coll Radiol 2016;13:e1-e29 
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Suspected Non–ST-Segment Elevation ACS: 
Observational Pathway—After Assessment of Serial Cardiac Troponin 
Rybicki et al . Appropriate Utilization of Cardiovascular Imaging in Emergency 
Department Patients With Chest Pain. J Am Coll Radiol 2016;13:e1-e29 
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Suspected PE 
Rybicki et al . Appropriate Utilization of Cardiovascular Imaging in Emergency 
Department Patients With Chest Pain. J Am Coll Radiol 2016;13:e1-e29 
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Suspected AAS 
Rybicki et al . Appropriate Utilization of Cardiovascular Imaging in Emergency 
Department Patients With Chest Pain. J Am Coll Radiol 2016;13:e1-e29 
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Rybicki et al . Appropriate Utilization of Cardiovascular Imaging in Emergency Department Patients 
With Chest Pain. J Am Coll Radiol 2016;13:e1-e29 
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CONCLUSION: CCTA in the ACP 
• CCTA has a high sensitivity (98-100%), Specificity 85% , NPV 100%. 
• Hs- Troponin is highly sensitive but less specific 
• Appropriate indications of CCTA : 
 CCTA as first test for low-intermediate risk pts with potential ACS 
 Safety: 30-day MACE < 1% 
 Efficiency 
 Lower ED costs of care 
 Equivocal initial diagnosis of NSTEMI/ACS 
 Serial troponins or ECG not positive for NSTEMI/ACS 
• Combination of hs Troponins and CCTA may play a valuable role in future 
strategies for the management of patients with ACP. 
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