Daniel O Bittner1, Thomas Mayrhofer2, Fabian Bamberg2, Travis R Hallett2, Sumbal Janjua2, Daniel Addison2, John T Nagurney2, James E Udelson2, Michael T Lu2, Quynh A Truong2, Pamela K Woodard2, Judd E Hollander2, Chadwick Miller2, Anna Marie Chang2, Harjit Singh2, Harold Litt2, Udo Hoffmann2, Maros Ferencik2. 1. From the Cardiac MR PET CT Program (D.O.B., T.M., F.B., T.R.H., S.J., D.A., M.T.L., U.H., M.F.), Department of Radiology (D.O.B., T.M., T.R.H., S.J., D.A., M.T.L., U.H., M.F.), and Department of Emergency Medicine (J.T.N.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Cardiology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Germany (D.O.B.); School of Business Studies, Stralsund University of Applied Sciences, Germany (T.M.); Department of Diagnostic and Interventional Radiology, University of Tuebingen, Germany (F.B.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Department of Radiology, Weill Cornell Medicine, New York City (Q.A.T.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO (P.K.W.); Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA (J.E.H., A.M.C.); Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC (C.M.); Penn State Heart and Vascular Institute, Hershey, PA (H.S.); Perelman School of Medicine of the University of Pennsylvania, Philadelphia (H.L.); and Knight Cardiovascular Institute, Oregon Health and Science University, Portland (M.F.). daniel.bittner@uk-erlangen.de. 2. From the Cardiac MR PET CT Program (D.O.B., T.M., F.B., T.R.H., S.J., D.A., M.T.L., U.H., M.F.), Department of Radiology (D.O.B., T.M., T.R.H., S.J., D.A., M.T.L., U.H., M.F.), and Department of Emergency Medicine (J.T.N.), Massachusetts General Hospital, Harvard Medical School, Boston; Department of Cardiology, University Hospital Erlangen, Friedrich-Alexander University Erlangen-Nürnberg (FAU), Germany (D.O.B.); School of Business Studies, Stralsund University of Applied Sciences, Germany (T.M.); Department of Diagnostic and Interventional Radiology, University of Tuebingen, Germany (F.B.); Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA (J.E.U.); Department of Radiology, Weill Cornell Medicine, New York City (Q.A.T.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO (P.K.W.); Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA (J.E.H., A.M.C.); Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC (C.M.); Penn State Heart and Vascular Institute, Hershey, PA (H.S.); Perelman School of Medicine of the University of Pennsylvania, Philadelphia (H.L.); and Knight Cardiovascular Institute, Oregon Health and Science University, Portland (M.F.).
Abstract
BACKGROUND: Coronary artery calcification (CAC) may impair diagnostic assessment of coronary computed tomography angiography (CTA). We determined whether CAC affects efficiency of coronary CTA in patients with suspected acute coronary syndrome (ACS). METHODS AND RESULTS: This is a pooled analysis of ACRIN-PA (American College of Radiology Imaging Network-Pennsylvania) 4005 and the ROMICAT-II trial (Rule Out Myocardial Infarction/Ischemia Using Computer Assisted Tomography) comparing an initial coronary CTA strategy to standard of care in acute chest pain patients. In the CTA arms, we investigated appropriateness of downstream testing, cost, and diagnostic yield to identify patients with obstructive coronary artery disease on subsequent invasive coronary angiography across CAC score strata (Agatston score: 0, >0-10, >10-100, >100-400, >400). Out of 1234 patients (mean age 51±8.8 years), 80 (6.5%) had obstructive coronary artery disease (≥70% stenosis) and 68 (5.5%) had ACS. Prevalence of obstructive coronary artery disease (1%-64%), ACS (1%-44%), downstream testing (4%-72%), and total (2337-8484 US$) and diagnostic cost (2310-6678 US$) increased across CAC strata (P<0.001). As the increase in testing and cost were lower than the increase of ACS rate in patients with CAC>400, cost to diagnose one ACS was lowest in this group (19 283 US$ versus 464 399 US$) as compared with patients without CAC. The diagnostic yield of invasive coronary angiography was highest in patients with CAC>400 (87% versus 38%). CONCLUSIONS: Downstream testing, total, and diagnostic cost increased with increasing CAC, but were found to be appropriate because obstructive coronary artery disease and ACS were more prevalent in patients with high CAC. In patients with acute chest pain undergoing coronary CTA, cost-efficient testing and excellent diagnostic yield can be achieved even with high CAC burden. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifiers: NCT01084239 and NCT00933400.
BACKGROUND: Coronary artery calcification (CAC) may impair diagnostic assessment of coronary computed tomography angiography (CTA). We determined whether CAC affects efficiency of coronary CTA in patients with suspected acute coronary syndrome (ACS). METHODS AND RESULTS: This is a pooled analysis of ACRIN-PA (American College of Radiology Imaging Network-Pennsylvania) 4005 and the ROMICAT-II trial (Rule Out Myocardial Infarction/Ischemia Using Computer Assisted Tomography) comparing an initial coronary CTA strategy to standard of care in acute chest pain patients. In the CTA arms, we investigated appropriateness of downstream testing, cost, and diagnostic yield to identify patients with obstructive coronary artery disease on subsequent invasive coronary angiography across CAC score strata (Agatston score: 0, >0-10, >10-100, >100-400, >400). Out of 1234 patients (mean age 51±8.8 years), 80 (6.5%) had obstructive coronary artery disease (≥70% stenosis) and 68 (5.5%) had ACS. Prevalence of obstructive coronary artery disease (1%-64%), ACS (1%-44%), downstream testing (4%-72%), and total (2337-8484 US$) and diagnostic cost (2310-6678 US$) increased across CAC strata (P<0.001). As the increase in testing and cost were lower than the increase of ACS rate in patients with CAC>400, cost to diagnose one ACS was lowest in this group (19 283 US$ versus 464 399 US$) as compared with patients without CAC. The diagnostic yield of invasive coronary angiography was highest in patients with CAC>400 (87% versus 38%). CONCLUSIONS: Downstream testing, total, and diagnostic cost increased with increasing CAC, but were found to be appropriate because obstructive coronary artery disease and ACS were more prevalent in patients with high CAC. In patients with acute chest pain undergoing coronary CTA, cost-efficient testing and excellent diagnostic yield can be achieved even with high CAC burden. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifiers: NCT01084239 and NCT00933400.
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