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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.
JACC Cardiovasc Imaging. 2015 Nov; 8(11):1272-1281.JC

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).

Authors+Show Affiliations

Knight Cardiovascular Institute, Oregon Health and Science University, Portland, OR. Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA. Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA.Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA. Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA. Department of Radiology, First Affiliated Hospital of China Medical University, Shenyang, China.Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA. Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA.Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA. Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA. Department of Biomedical Imaging and Image-Guided Therapy, Medical University Vienna, Vienna, Austria.Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA. Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA.TA-SE Lendület Cardiovascular Imaging Research Group, Heart and Vascular Centre, Semmelweis University, Budapest, Hungary.Department of Emergency Medicine, Baystate Medical Center, Springfield, MA.Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA. Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA. Dalio Institute of Cardiovascular Imaging, New York-Presbyterian Hospital and Weill Cornell Medical College.Division of Cardiology and the Cardio-Vascular Center, Tufts Medical Center, Boston, MA.Department of Emergency Medicine, Baylor College of Medicine, Houston, TX.University of Maryland School of Medicine, Baltimore, MD.Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO.Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD.Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA.Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA.Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA. Cardiac MR PET CT Program, Massachusetts General Hospital and Harvard Medical School, Boston, MA. Cardiology Division, Massachusetts General Hospital and Harvard Medical School, Boston, MA.

Pub Type(s)

Comparative Study
Journal Article
Multicenter Study
Observational Study
Randomized Controlled Trial
Research Support, N.I.H., Extramural

Language

eng

PubMed ID

26476506

Citation

Ferencik, Maros, et al. "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." JACC. Cardiovascular Imaging, vol. 8, no. 11, 2015, pp. 1272-1281.
Ferencik M, Liu T, Mayrhofer T, et al. 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. JACC Cardiovasc Imaging. 2015;8(11):1272-1281.
Ferencik, M., Liu, T., Mayrhofer, T., Puchner, S. B., Lu, M. T., Maurovich-Horvat, P., Pope, J. H., Truong, Q. A., Udelson, J. E., Peacock, W. F., White, C. S., Woodard, P. K., Fleg, J. L., Nagurney, J. T., Januzzi, J. L., & Hoffmann, U. (2015). 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. JACC. Cardiovascular Imaging, 8(11), 1272-1281. https://doi.org/10.1016/j.jcmg.2015.06.016
Ferencik M, et al. 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. JACC Cardiovasc Imaging. 2015;8(11):1272-1281. PubMed PMID: 26476506.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - 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. AU - Ferencik,Maros, AU - Liu,Ting, AU - Mayrhofer,Thomas, AU - Puchner,Stefan B, AU - Lu,Michael T, AU - Maurovich-Horvat,Pal, AU - Pope,J Hector, AU - Truong,Quynh A, AU - Udelson,James E, AU - Peacock,W Frank, AU - White,Charles S, AU - Woodard,Pamela K, AU - Fleg,Jerome L, AU - Nagurney,John T, AU - Januzzi,James L, AU - Hoffmann,Udo, Y1 - 2015/10/14/ PY - 2015/04/06/received PY - 2015/06/04/revised PY - 2015/06/04/accepted PY - 2015/10/19/entrez PY - 2015/10/20/pubmed PY - 2016/9/16/medline KW - acute coronary syndrome KW - coronary computed tomography angiography KW - coronary plaque KW - emergency department KW - highly sensitive troponin KW - risk stratification SP - 1272 EP - 1281 JF - JACC. Cardiovascular imaging JO - JACC Cardiovasc Imaging VL - 8 IS - 11 N2 - 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). SN - 1876-7591 UR - https://www.unboundmedicine.com/medline/citation/26476506/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_ L2 - https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/26476506/ DB - PRIME DP - Unbound Medicine ER -