Coronary Artery Disease Clinical Trial
Official title:
Utility of 64-slice Multidetector CT Coronary Angiography in the Evaluation of Low to Intermediate Risk ED Patients
The purpose of this study is to evaluate whether 64-slice Computed Tomographic coronary angiography is useful for rapid diagnosis or exclusion of significant coronary artery disease in patients who present to the Emergency Department with chest pain.
The acute coronary syndromes (ACS), which encompass unstable angina (UA) and both ST
elevation and non-ST elevation myocardial infarction (STEMI and non-STEMI), are the leading
cause of death in the United States. In addition, they account for a significant number of
hospital admissions (300,000 per year for STEMI, >1,000,000 per year for non-ST elevation
ACS). Differentiation of patients with ACS from those with chest pain due to other causes,
as well as risk stratification of those within the ACS group, are critically important.
In the Emergency Department(ED), the ECG is initially used to distinguish patients with
STEMI from those with non-STEMI and other ACS. Subsequent workup in non-STEMI patients is
aimed at rapidly distinguishing those who require admission and possible intervention or
intensive medical therapy, from those who can be safely discharged. However, because of the
frequent inability to determine whether symptoms are related to an ACS during this initial
ED visit, further evaluation is often needed, resulting in an estimated 5,000,000 admissions
per year.
Currently, a variety of modalities are used in this process of risk stratification, with
resting myocardial perfusion imaging (MPI) often assuming a central role. This modality has
an overall sensitivity of 80% and an excellent negative predictive value (95-97%). Resting
MPI therefore enables clinicians to safely triage low risk patients to delayed stress
testing or discharge. However, as with any test, this technique has limitations, including
an increased incidence of equivocal findings in obese patients, lower sensitivity in
patients without ongoing symptoms, and unsuitability in patients with previous myocardial
damage. Perhaps most importantly, alternative diagnoses such as aortic dissection or
pulmonary embolism cannot be evaluated with myocardial perfusion imaging.
If coronary Computed Tomographic angiography (CTA) could be shown to be a robust technique
in the clinical setting, it could become a powerful tool in the triage of patients with ACS.
Computed Tomography (CT) of the chest is currently considered the gold standard for
evaluation of the two most common serious alternative chest pain diagnoses - aortic
dissection and pulmonary embolism. A single, rapid comprehensive imaging study that could
reliably diagnose or exclude coronary artery disease, aortic dissection, and pulmonary
embolism would allow quicker and more appropriate triage of this acutely ill population.
However, in keeping with the principles of evidence-based medicine, before comprehensive
gated chest CT angiography can be recommended in preference to existing techniques,
systematic comparative studies should be performed. In this study, the results of the CTA
will be compared with those of the resting MPI, which is part of the standard ED evaluation
of chest pain at this institution. In addition, a majority of these patients subsequently
undergo stress MPI. It is therefore anticipated that the stress MPI results will also be
compared with the CTA findings.
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