- Email: [email protected]
Secondary cardiac risk stratifying tests after coronary computed tomography angiography in emergency department patients
Accepted Manuscript Secondary cardiac risk stratifying tests after coronary computed tomography angiography in emergency department patients Vincent A. Verheij, Jan-Erik Scholtz, Nandini M. Meyersohn, Blair A. Parry, Udo Hoffmann, Brian B. Ghoshhajra, John T. Nagurney PII:
S1934-5925(18)30123-0
DOI:
10.1016/j.jcct.2018.10.005
Reference:
JCCT 1146
To appear in:
Journal of Cardiovascular Computed Tomograph
Received Date: 22 May 2018 Revised Date:
15 September 2018
Accepted Date: 2 October 2018
Please cite this article as: Verheij VA, Scholtz J-E, Meyersohn NM, Parry BA, Hoffmann U, Ghoshhajra BB, Nagurney JT, Secondary cardiac risk stratifying tests after coronary computed tomography angiography in emergency department patients, Journal of Cardiovascular Computed Tomograph (2018), doi: https://doi.org/10.1016/j.jcct.2018.10.005. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Secondary Cardiac Risk Stratifying Tests after Coronary Computed
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Tomography Angiography in Emergency Department Patients
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Autohors
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Vincent A. Verheij, M.D.a
[email protected]
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Jan-Erik Scholtz, M.D.b
[email protected]
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Nandini M. Meyersohn, M.D.b
[email protected]
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Blair A. Parry, B.A.c
[email protected]
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Udo Hoffmann, M.D., M.P.H.b
[email protected]
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Brian B. Ghoshhajra, M.D., M.B.A.b*
[email protected]
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John T. Nagurney, M.D., M.P.H.a#
[email protected]
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Affiliations
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a. Department of Emergency Medicine
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Massachusetts General Hospital & Harvard Medical School
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55 Fruit Street, Boston, Massachusetts, 02114, USA
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Phone: +1 617-726-7623
b. Cardiac MR PET CT Program Department of Radiology and Division of Cardiology
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Massachusetts General Hospital & Harvard Medical School
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55 Fruit Street, Boston, Massachusetts, 02114, USA
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c. Department of Emergency Medicine and Division of Research
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Massachusetts General Hospital
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5 Emerson Place, Boston, Massachusetts, 02114, USA
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Co-senior author
# Corresponding author
ACCEPTED MANUSCRIPT Conflicts of interest
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This research did not receive any specific grant from funding agencies in the public,
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commercial or not-for-profit sectors.
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ACCEPTED MANUSCRIPT
Secondary Cardiac Risk Stratifying
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Tests after Coronary Computed
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Tomography Angiography in
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Emergency Department Patients
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Abstract
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Background
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Several large trials demonstrated that coronary computed tomography angiography
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(CTA) in a triage strategy could lead to increased secondary cardiac risk stratifying
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testing (SCRST). Whether this is true for routine clinical care remains unclear. We
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measured SCRSTs after coronary CTA was implemented in our emergency
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department (ED) practice by CTA result, and if locally existing management
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recommendations for a structured post CTA diagnostic strategy were followed.
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Methods
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This single site retrospective cohort study included all our ED patients who received
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coronary CTA between October 1, 2012 and September 30, 2016. SCRST’s
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included functional cardiac tests and invasive coronary angiography (ICA),
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performed during the ED coronary CTA visit or related admission.
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ACCEPTED MANUSCRIPT Results
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A total of 1916 subjects were included with a mean age of 52.9 ±10.8 years. Of their
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coronary CTAs, 179 were positive (severe stenosis, occlusion or ventricular wall
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motion abnormalities; 9.3%), 105 intermediate (moderate stenosis; 5.5%), 1611
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negative (no to mild obstructive CAD; 84.1%) and 21 non-diagnostic (1.1%).
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SCRSTs were performed in 237 (overall 12.4%, noninvasive in 5.6%, ICA in 6.7%).
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After positive coronary CTA, 73.7% of subjects received SCRSTs. For intermediate,
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negative and non-diagnostic CTAs this was 72.4%, 1.1% and 47.6% respectively.
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Management conformed to local management recommendations in 96.2% of cases.
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Conclusion
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In spite of previous trials, rates of secondary cardiac risk stratifying tests after routine
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clinical ED coronary CTA are low, especially in patients with negative coronary CTA.
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Structured management guidelines for post coronary CTA, and adherence to these
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guidelines, appear essential.
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Key words
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Acute Chest Pain; Acute Coronary Syndrome; Coronary CTA; Downstream Testing;
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Secondary Cardiac Risk Stratifying Tests;
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ACCEPTED MANUSCRIPT TOC Summary
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Several large controlled trials demonstrated that coronary CTA in a triage strategy
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could lead to increased downstream cardiac testing. Using data of four years of
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clinical coronary CTA use, this study retrospectively investigated whether this is true
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when ED coronary CTA is implemented in routine clinical ED practice.
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ACCEPTED MANUSCRIPT Abbreviations
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ED – Emergency department
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ACS – Acute coronary syndrome
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CTA – Computed tomography angiography
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CAD – Coronary artery disease
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SCRST – Secondary cardiac risk stratifying test
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ETT – Exercise tolerance test
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MPI – Myocardial perfusion imaging
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SPECT – Single-photon emission computed tomography
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CMR – Cardiovascular magnetic resonance imaging
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PET – Positron emission tomography
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hs-cTn – High sensitive cardiac troponin
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eGFR – Estimated glomerular filtration rate
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ECG – Electrocardiography
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PA – Physician Assistant
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SDU – Step down unit
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CCU – Coronary care unit
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CAD-RADS – Coronary artery disease reporting and data system
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ICA – Invasive coronary angiography
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VWMA – Ventricular wall motion abnormality
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TTE – Transthoracic echocardiogram
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TEE – Transesophageal echocardiogram
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MRI – Magnetic resonance imaging
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PCP – Primary care physician
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AMA – Against medical advise
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ACCEPTED MANUSCRIPT 1. Introduction
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Nonspecific chest pain is the second most frequent first-listed medical diagnosis for
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emergency department (ED) visits in the US with an incidence increase of 26% from
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2006 to 2014.1 Coronary atherosclerosis however showed the greatest decrease
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amongst first-listed medical diagnosis with 34% over the same period.1 Hence rapid
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and efficient triage strategies for patients with possible acute coronary syndromes
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(ACS) are crucial.
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Recently, coronary computed tomography angiography (coronary CTA)2 has
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been added to the diagnostic armamentarium for low- to intermediate-risk ACS
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patients.3 This new risk stratification weapon allows for the noninvasive visualization
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of obstructive coronary plaques or stenoses, and enables assessment of valves and
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regional resting ventricular wall motions.4–6 Although coronary CTA evaluates the
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anatomical aspects of coronary artery disease (CAD), as opposed to classic
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functional tests, multiple studies have shown that if coronary CTA is negative for
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significant luminal narrowing, the likelihood of ACS is very low.7–9 In addition, use of
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coronary CTA has been shown to result in reduction in length of stay and increased
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ED discharge rates with exceptionally low major adverse clinical events.10–14
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Nonetheless, several controlled trials noted that a potential drawback of ED
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coronary CTA implementation is increased downstream testing and costs of
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diagnostic evaluation.12–15 Whether this is true for post CTA tests with routine clinical
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use however is unclear. The aim of this study was to measure secondary cardiac risk
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stratifying testing(SCRST) in all our ED patients who had received coronary CTA as
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part of routine clinical care. SCRSTs were included if they occurred during the visit
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when ED coronary CTA was performed or during a related admission (including
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those to the ED observation unit). Our secondary aim was to measure adherence to
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locally designed management recommendations to evaluate their effect on
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downstream testing rates.16
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2. Methods 2.1. Study Design We performed a single site, retrospective cohort study using data from our
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consecutive case coronary CTA registry. This is a registry of all coronary CTAs that
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are performed on adult patients at an ED visit, or their related admission to the ED
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observation unit, as part of routine clinical care. It also includes all other cardiac tests
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that occurred during that visit or related admission, and has previously been
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approved by our institutional review board. Informed consent was waived due to the
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retrospective design of the study.
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2.2. Setting and Location
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The setting was the ED of an American academic medical center with an average
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annual ED patient volume of 106,000. In this tertiary hospital, where two observation
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units totaling 34 beds are part of the ED, coronary CTA was implemented into
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routine clinical care in October 2012 and is performed on two dual-source CT-
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scanners, one of which is located in the ED. Purely based on their preference,
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emergency physicians were free to choose either this anatomical assessment for
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primary cardiac risk stratification, or conventional stress testing, including exercise
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tolerance testing without imaging (ETT), stress-induced myocardial perfusion
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imaging (MPI/SPECT) or stress ultrasound testing (dobutamine or exercise
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echocardiogram). Stress myocardial perfusion cardiovascular magnetic resonance
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imaging (CMR) and positron emission tomography (PET) are not commonly
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performed in our hospital on potential ACS ED patients. No advanced diagnostic
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pathways such as the HEART
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or EDACS
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scores were used in our ED at the
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time of intake for this study, nor were high-sensitivity cardiac troponin (hs-cTn)
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assays available at the time. Eligible criteria for coronary CTA did not restrict patients based on heart rate,
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rhythm or body habitus but recommended relative contraindications were known
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CAD or prior revascularizations, impaired renal function (eGFR < 60mL/min/1.73m2),
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contrast-allergy and serum biomarker levels or ECG changes suggestive of
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myocardial ischemia.
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All scans were physician-supervised during gradually expanded operating
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hours, with protocols as previously published.16,19 A non-contrast coronary calcium
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scan was obtained in all patients but contrast-enhanced scans were performed
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regardless of coronary calcium burden. Unless contraindicated, 600 mcg of
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sublingual nitroglycerin was administered at least 5 minutes prior to an arterial bolus-
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timed contrast-enhanced CTA. Prospective ECG triggering, with widening of the
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acquisition window to include end-systole and late-diastole, or retrospective ECG
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gating was performed depending on heart rate and rhythm, to allow for functional
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assessment in nearly all patients, as detailed.19 Board certified and subspecialty-
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trained cardiovascular radiologists interpreted images in real time and results were
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immediately called back to the referring ED providers to facilitate a dialogue between
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the reader and referring provider on appropriate further management. Decision
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makers in the ED were residents or physician assistants (PA) and in the ED
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Observation Units nurse practitioners or PAs. SCRSTs may not have been ordered
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by the provider who originally ordered the coronary CTA, but all decision makers
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were familiar with the same post CTA management recommendations and were
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supervised by board certified or board eligible emergency physicians at any time.
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ECGs were reviewed by ED attending physicians in real time.
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ACCEPTED MANUSCRIPT ED patients were typically discharged home, admitted to an ED Observation
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Unit for further evaluation, admitted to an Internal Medicine floor, a general
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cardiology floor, a step-down unit (SDU) or a coronary care unit (CCU), depending
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on the results of their ED evaluation. Figure 1 shows the typical flow of potential ED
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ACS patients through the ED, their paths to the provider’s preferred ischemic risk
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stratifying test and possible subsequent testing.
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2.3. Study Population
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Our research involved a consecutive registry of ED patients in whom coronary CTA
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was used as a clinical risk stratifying test. Patients were included if their ED coronary
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CTA was performed between October 1, 2012 and September 30, 2016. Excluded
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were those with a documented elevated Troponin-T ≥ 0.03 ηg/mL prior to their
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coronary CTA, because they would normally not receive coronary CTA due to their
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high likelihood of ACS. If two attempts to scan were made for the same patient (e.g.
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due to an IV-catheter problem with the first) only the one with the completed scan
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was included.
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Strict guidelines for patient management after coronary CTA did not exist at the
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beginning of the registry given that the early Society of Cardiovascular Computerized
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Tomography guidelines for coronary CTA reporting did not include treatment
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guidelines.20 However, a multidisciplinary site “task force” was originally created to
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lay out non-binding local management recommendations based on existing
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literature. ED providers were informed of these management recommendations by
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presentations at staff meetings and didactic sessions, through posts on the
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Emergency Medicine intranet and by discussions with the CTA reviewers when
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results were verbally reported.
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ACCEPTED MANUSCRIPT Towards the end of our study period, the Coronary Artery Disease Reporting
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and Data System (CAD-RADS, Appendix)21 definitions and recommendations were
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published. Since they were identical to our traditional site thresholds of stenosis
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grading and management recommendations, they then became standard practice.
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Specific recommendations for post coronary CTA management were as follows; no
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further cardiac investigations should be performed after negative coronary CTA
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(CAD-RADS 0-2); a physiologic cardiac risk stratification test should be performed
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after intermediate (CAD-RADS 3) or non-diagnostic scans (CAD-RADS “N”); and
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cardiology consultation should be obtained for patients with positive coronary CTA
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(defined as CAD-RADS 4-5 or any ventricular wall motion abnormalities(VWMA)).
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VWMAs are not covered by the CAD-RADS paradigm but have been shown to have
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incremental diagnostic yield and were therefore believed to warrant cardiology
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consultation.22 It was further recommended that exceptions should be made on a
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per-patient basis (e.g. coronary CTA resulting in CAD-RADS modified “V” –
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vulnerable plaque). No specific recommendations were made for non-risk stratifying
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cardiac tests in the face of an abnormal coronary CTA.
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2.5. Definition of Primary Outcome All cardiac tests performed after coronary CTA but during the same ED visit or
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related admission were counted and scored risk stratifying or non-risk stratifying
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tests. SCRSTs were any additional cardiac risk stratifying tests; ETT, MPI/SPECT,
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stress ultrasound or invasive coronary angiography (ICA). These subsequent cardiac
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tests were then categorized by the results of the coronary CTA.
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2.6. Definition of Secondary Outcome
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Providers were considered to have followed local management recommendations if
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as phone discussions with cardiologists, during the ED coronary CTA visit or related
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admission. Cardiac tests that do not increase myocardial demand (e.g. transthoracic
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echocardiogram (TTE), transesophageal echocardiogram (TEE), resting cardiac MRI
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and FDG-18 study (cardiac PET scan) were also in our registry, but were excluded
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from our primary analysis as they do not stratify for cardiac ischemic risks. These
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cardiac non-risk stratifying tests were reviewed and described separately. They were
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considered appropriate if the coronary CTA demonstrated cardiac abnormalities, if
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the cardiac imager recommended a non-stress echo or if the ECG was abnormal.
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2.7. Data Collection, Management and Analysis
Data from our online registry (Research Electronic Data Capture tool (REDCap)
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v6.15.11 – Vanderbilt University, Nashville, TN) were downloaded onto a Microsoft
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Excel spreadsheet (Microsoft Office Professional Plus 2007 v12.0.6765.5000 –
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Microsoft Corporation, Redmond, WA) and used for analysis. More specifics about
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the validated data entry methods used have been previously published.16,23 Coronary
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CTA results and secondary cardiac tests were reviewed by the principal investigator,
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the registry keeper, the senior cardiac imager and the senior investigator.
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Adjudication was made by consensus. Descriptive statistics were used with means,
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medians, percentages, and when appropriate, 95% confidence intervals or standard
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deviations.
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3. Results 3.1. Subject characteristics A total of 1924 ED coronary CTA records were created during the four year intake
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period of our study. One patient had two records from the same ED visit of which the
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first was excluded because the CTA was aborted after the IV catheter malfunctioned
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and therefore had to be re-ordered the following day. Seven other records were
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excluded because of elevated initial serum cardiac biomarkers. The mean age of the
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included 1916 patients was 52.9 ±10.8 years and 55.4% were male. These and other
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detailed baseline subject characteristics are listed in Table 1.
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3.2. Secondary Cardiac Risk Stratifying Testing and Adherence to Recommendations.
Figure 2 demonstrates all subjects’ final coronary CTA results and lists SCRSTs by
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corresponding management recommendations. Overall, 237 subjects (12.4%; 95%
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CI 10.9% to 13.8%) received one or more noninvasive SCRSTs (5.6%) or ICA
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(6.8%) during their ED coronary CTA visit or related admission. Five subjects
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received their SCRST from the ED, 66 from the ED observation unit and 166 from
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other inpatient floors. Subsequent diagnostic steps followed local management
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recommendations in 1844 (96.2%; 95% CI 95.4% to 97.1%).
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A total of 179 (9.3%; 95% CI 8.0% to 10.6%) subjects had positive coronary
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CTA (CAD-RADS 4-5 or VWMA). In 146 (81.6%) this was due to actual obstructive
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CAD and in 33 (18.4%) this was solely due to VWMAs without the presence of
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obstructive CAD (CAD-RADS 0-3). Of these 179 positive coronary CTA subjects,
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165 (92.2%; 95% CI 91.0 to 93.4%) received cardiology consultation, resulting in 132
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(64.8%) (Figure 3) and physiologic SCRSTs only in 25 (15.2%) cases. Thirty-three
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(20.0%) consulted subjects received no SCRSTs at all (Figure 4). Fourteen (7.8%) subjects with positive coronary CTA did not receive
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cardiology consultation. Eight had only regional ventricular wall motion abnormalities
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and were advised to follow up with their primary care provider (PCP) and another
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three left against medical advice(AMA). One of the remaining three subjects received
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an SCRST making the total of positive subjects with SCRSTs 133 (74.3%; 95% CI
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72.3% to 76.3%).
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Coronary CTA was intermediate in 105 (5.5%; 95% CI 4.5% to 6.5%) subjects
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of which 76 (72.4%; 95% CI 70.4% to 74.4%) received SCRSTs, with 21 (20.0%)
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receiving at least ICA. Of the 29 (27.6%) subjects that did not receive SCRSTs, 19
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(65.5%) were seen by a cardiologist, eight during the same ED visit or related
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admission and 11 within a month of the index visit. Four subjects were scheduled for
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an SCRST but left prior to imaging. The remaining subjects underwent follow up care
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elsewhere or were admitted for other reasons.
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Together, 1611 (84.1%; 95% CI 82.4% to 85.7%) coronary CTAs were
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negative of which eighteen (1.1%, 95% CI 0.6% to 1.6%) received SCRSTs. In six
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cases, SCRSTs were recommended by a cardiologist, in another two were concerns
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about ECG abnormalities, one SCRST was recommended per CTA result and one
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coronary CTA result was misinterpreted by ED providers. All SCRSTs after negative
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coronary CTA were negative for ischemia, except one which demonstrated either an
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artifact or a very small territory of mild anterolateral ischemia without evidence of
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infarction.
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3.3. Non-diagnostic Coronary CTA Twenty-one (1.1%; 95% CI 0.6% to 1.6%) subjects received non-diagnostic coronary
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CTA. In two, obstructive disease could not be excluded because the coronary CTA
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was aborted after allergic reactions to the test bolus of iodine. Other reasons for
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limited evaluation were motion artifacts (7), suboptimal contrast opacification (5),
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body habitus (4) or extensive coronary artery calcification (3). Eleven of the non-
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diagnostic coronary CTAs (52.4%; 95% CI 50.1% to 54.6%) were not followed by
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SCRSTs, of which four were told to follow up with their PCP. Another four had no
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luminal narrowing in the visualized segments and one received cardiology
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consultation.
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3.4. Cardiac Non-Risk Stratifying Tests
A total of 75 (3.9%; 95% CI 3.0% to 4.8%) subjects received cardiac non-risk
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stratifying tests after coronary CTA. Seventy-three (97.3%) received TTE, one
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(1.3%) TEE and one (1.3%) had both. Most (n=67, 89.3%) were performed in
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subjects with abnormal coronary CTA (n=4), with non-coronary pathologic findings
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(n=22), with ECG abnormalities (n=1) or with a combination of the above (n=40) but
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in eight (10.7%) cases we could not find any indication for the performed
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ultrasounds.
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4. Discussion 4.1. Secondary cardiac risk stratifying testing after ED coronary CTA In the ED of an academic medical center that was early to embrace clinical coronary
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CTA to rule out ACS, routine CTA use led to downstream testing in 12.4% of
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patients. This relatively low number includes noninvasive testing (5.6%), invasive
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coronary angiography (6.1%) and both (0.6%) in a population with 84.1% negative
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coronary CTA results (CAD-RADS 0-2).
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Two large studies from the early coronary CTA trial-era demonstrated increased
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overall downstream testing in their coronary CTA-arm compared to standard of
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care.11,12 In the multicenter ACRIN-PA trial11, 17.7% of all potential ACS ED subjects
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randomly assigned to coronary CTA underwent SCRSTs, and the rate of
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downstream testing during the similar multicenter ROMICAT-II trial12 was 23.2%.
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From these preliminary trials, it would appear as if the advantage of coronary CTA,
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i.e. the ability to identify pre-symptomatic lesions, results in more downstream testing
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through pursuit of the exact ischemic burden of visualized non-obstructing plaques.
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Our total downstream testing rate of 12.4% however, is considerably lower,
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despite seemingly similar populations. We were unable to report, and thus compare
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ACS rates as complete 60-day follow-up was ascertained in only the first 550
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subjects. However, using abnormal result percentages as a proxy for prevalence of
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ACS demonstrates how our population appears to have been similar to ACRIN-PA
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and ROMICAT-II24. Our percent of abnormal CTAs (intermediate, positive or non-
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diagnostic) was 15.9 compared to 21.4% in the ACRIN-PA study and 16.6% in the
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ROMICAT-II study. And while for the same reason we could not report on tests
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hospitalization, prior experience from the ROMICAT-II trial demonstrated that
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SCRSTs are primarily performed during the ED coronary CTA visit or related
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admission. (Of 139 SCRSTs performed on 473 ED coronary CTA subjects, 83.5%
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was performed during the ED coronary CTA visit or related admission.25) Hence, our
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lower downstream testing rate is not likely related to disease prevalence or lack of
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follow-up.
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Our hypothesis is that our SCRST rate reflects a learning curve at our
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institution. After careful implementation of coronary CTA into our ED practice
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(demonstrated
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recommendations of 96.2%) our SCRST usage presumably reduced with growing
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clinical practice. While only about a dozen ED coronary CTAs were ordered during
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the first few months of its implementation, coronary CTA quickly gained popularity.
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We currently perform them on a daily basis, allowing us to include almost 2000
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subjects in 4 years. This increased clinical use and experience suggests an ample
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‘real world’ experience over years. ACRIN-PA and ROMICAT-II on the other hand
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had intake periods prior to November 2011, when providers had little or no
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antecedent experience with coronary CTA patient management. Our experience is
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further corroborated by the fact that our SCRST rate approaches the 10.6% of
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SCRSTs performed in subjects with well established, standards of care during
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ROMICAT-II. In addition, the rate of ICA in our study was also lower than reported in
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ROMICAT-II (6.8% vs. 10.8%), suggesting increasing confidence on the part of
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providers that coronary CTA accurately identifies non-obstructive coronary
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atherosclerotic plaque.
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ACCEPTED MANUSCRIPT Two other studies similarly reported rates of SCRSTs, by coronary CTA result,
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after implementation of coronary CTA in ED practice.26,27 In most groups, SCRST
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usage was fairly similar, but only 1.1% of the vast majority of our population was sent
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to obtain SCRSTs versus Cury’s 3.2% and Uretsky’s 15.5% of negative cases. Thus,
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fears of unnecessary “layering” of cardiac tests do not seem justified.28 Nevertheless,
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the latter studies were also reported early in the clinical ED coronary CTA era,
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explaining their defensive approaches. Since then, data have accumulated that
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consistently demonstrate the powerful negative predictive values of coronary CTA to
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identify patients safe for discharge21, encouraging physicians to hold back on
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additional testing.
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Interestingly, with growing coronary CTA experience around the globe, a
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recent trail in fact demonstrated how downstream testing decreased with coronary
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CTA.29 The Dutch BEACON study, a randomized multicenter trial investigating
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coronary CTA effectiveness, did not show reduction of length of stay (presumably
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due to recent implementation of hs-Troponins) and was underpowered to report a
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difference in identification of significant CAD requiring coronary revascularization.
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However, it did demonstrate significantly lower evaluation costs (34%) and less
345
subsequent outpatient testing in their CTA arm (10% vs. 26%). Numerous factors
346
clearly limit result comparability, let alone generalizability of these European results
347
to American medical centers30, but the BEACON results appear promising. While
348
including patients with mildly elevated troponins, in a health care system like the
349
European’s where very low-risk patients are screened out of EDs by a general
350
practitioner or by ambulance triage31, downstream testing did not increase. Then
351
again, this study was performed in a region where medical workup may not be as
352
defensive as the American, due to less fear of litigation and fewer limitations in
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ACCEPTED MANUSCRIPT securing outpatient follow up visits.32,33 Also, their outcome measure was outpatient
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testing within 48-72h of the index ED visit as opposed to work-up during the index
355
visit or related admission. But with all that aside, this trial could suggest that coronary
356
CTA has the potential to reduce cardiac risk stratifying test ‘shingling’.
357
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4.3. Evaluation
Our contribution is to show that use of coronary CTA in standard clinical practice
359
should not lead to more downstream testing. Nonetheless, half of a small group of
360
non-diagnostic coronary CTA subjects did not receive SCRSTs as was
361
recommended by our guidelines. Fortunately, most of these subjects received at
362
least cardiology consultation or were told to follow up with their primary care
363
provider. Future research projects could look into the value and yield of SCRSTs in
364
non-diagnostic coronary CTAs without obstructive CAD in the segments visualized.
365
Also, for positive coronary CTA subjects (CAD-RADS 4-5 or VWMA) who failed to
366
receive cardiology consultation (n=14; 7.8%) and subjects with intermediate coronary
367
CTA (CAD-RADS 3) without SCRSTs (n=29; 27.6%), our conjecture is that
368
appropriate care has still taken place. The majority of these subjects with positive
369
coronary CTA had only VWMAs without significant obstructive CAD and the majority
370
of the subjects with intermediate outcome CTA received cardiology consultation.
371
This suggests that our recommendation to pursue intermediate coronary CTA with
372
an SCRST may have competed with a seasoned cardiologists’ opinion on optimal
373
management. Nevertheless, a large number of subjects with positive coronary CTA
374
received no SCRST after their cardiology consultation. Consultation during the ED
375
visit or related admission led to further testing in 80.0%, with ICA in 64.8%.
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Cardiac non-risk stratifying tests were performed on a relatively large number
377
of subjects (n=75). These were usually TTEs and typically performed because the Page 18 of 34
ACCEPTED MANUSCRIPT coronary CTA was abnormal or because subjects had abnormal ECGs, but a small
379
number would appear to have been unnecessary. Future research projects could
380
determine whether this additional cardiac imaging changed clinical outcomes or
381
provided additional information to an anatomy assessing coronary CTA.
382
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4.4. Limitations
This study included a large population from a highly specialized center with
384
distinct ED coronary CTA experience. Hence, our results may not be generalizable
385
to other EDs. Additionally, we did not report on comparing risk stratifying strategies,
386
i.e. stress testing, to put our data in perspective. This study was merely a descriptive
387
study of practice. As it is not a safety study, it does not provide answers on who
388
should receive cardiac risk stratification or on what tests to use. The choice of
389
coronary CTA for cardiac risk stratification solely depended on provider preferences,
390
as there never were protocols on when to use coronary CTA. This limited the
391
discussion of factors influencing the decision to order a coronary CTA in the first
392
place. We also did not compare SCRSTs individually, as their availabilities are highly
393
center-specific and we had no recommendations on which SCRST to use
394
specifically. This choice was also left to the discretion of the physician.
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Also, although we used a consecutive case registry, data were gathered
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retrospectively, disallowing us from inferring why certain clinical actions were taken.
397
The value of SCRSTs performed in conjunction with coronary CTA, and whether
398
they added clinical value, could not be determined. Finally, ACS rates and outpatient
399
testing for our population could not be directly determined. Instead, without a
400
universally accepted standard to calculate a populations’ risk for ACS, we used our
401
abnormal coronary CTA percentage as a proxy for ACS prevalence.
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Coronary CTA as a first line tool to evaluate patients with acute chest pain in a busy
405
ED does not necessarily lead to increased downstream testing. In our tertiary
406
medical center, rates of downstream tests, especially for patients with negative
407
coronary CTA are lower than previous trials reported. A high adherence rate to
408
dedicated management guidelines for post coronary CTA may explain this.
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6. Appendix
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Copy of CAD-RADS Classification
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ACCEPTED MANUSCRIPT 7. Acknowledgements
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The authors gratefully acknowledge the enthusiastic support in literature analysis of
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Mrs. Martha E. Stone, M.S., coordinator for Research & Reference of the Treadwell
416
Library. We would also like to acknowledge the staffs of our Department of
417
Emergency Medicine and Emergency Cardiac CTA program.
418
8. Funding
419
This research did not receive any specific grant from funding agencies in the public,
420
commercial or not-for-profit sectors.
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9. References
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1.
Moore BJ, Stocks C, Owens PL. Trends in emergency department visits, 2006–2014. Healthc Cost Util Proj Stat Briefs. 2006;Statistica(December
425
2012):893-908. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb227-
426
Emergency-Department-Visit-Trends.pdf.
427
2.
RI PT
424
Weigold WG, Abbara S, Achenbach S, et al. Standardized medical terminology for cardiac computed tomography: a report of the Society of Cardiovascular
429
Computed Tomography. J Cardiovasc Comput Tomogr. 2011;5(3):136-144.
430
doi:10.1016/j.jcct.2011.04.004 3.
M AN U
431
SC
428
Wolk MJ, Bailey SR, Doherty JU, et al.
ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013
433
multimodality appropriate use criteria for the detection and risk assessment of
434
stable ischemic heart disease: a report of the American College of Cardiology
435
Foundation Appropriate Use Criteria Task Forc. J Card Fail. 2014;20(2):65-90.
436
doi:10.1016/j.cardfail.2013.12.002 4.
AC C
of coronary artery stenosis in individuals without known coronary artery
439
disease: results from the prospective multicenter ACCURACY (Assessment by
440
Coro. J Am Coll Cardiol. 2008;52(21):1724-1732.
441
doi:10.1016/j.jacc.2008.07.031
442
444
Budoff MJ, Dowe D, Jollis JG, et al. Diagnostic performance of 64multidetector row coronary computed tomographic angiography for evaluation
438
443
EP
437
TE D
432
5.
Meijboom WB, Meijs MFL, Schuijf JD, et al. Diagnostic accuracy of 64-slice computed tomography coronary angiography: a prospective, multicenter,
Page 23 of 34
ACCEPTED MANUSCRIPT 445
multivendor study. J Am Coll Cardiol. 2008;52(25):2135-2144.
446
doi:10.1016/j.jacc.2008.08.058
447
6.
Shapiro MD, Dodd JD, Kalva S, et al. A comprehensive electrocardiogramgated 64-slice multidetector computed tomography imaging protocol to
449
visualize the coronary arteries, thoracic aorta, and pulmonary vasculature in a
450
single breath hold. J Comput Assist Tomogr. 2009;33(2):225-232.
451
doi:10.1097/RCT.0b013e31817c12b1 7.
SC
452
RI PT
448
Hollander JE, Litt HI, Chase M, Brown AM, Kim W, Baxt WG. Computed tomography coronary angiography for rapid disposition of low-risk emergency
454
department patients with chest pain syndromes. Acad Emerg Med.
455
2007;14(2):112-116. doi:10.1197/j.aem.2006.09.051
456
8.
M AN U
453
Cury RC, Feutchner G, Pena CS, Janowitz WR, Katzen BT, Ziffer JA. Acute chest pain imaging in the emergency department with cardiac computed
458
tomography angiography. J Nucl Cardiol. 2008;15(4):564-575.
459
doi:10.1016/j.nuclcard.2008.05.006 9.
Hoffmann U, Bamberg F, Chae CU, et al. Coronary computed tomography angiography for early triage of patients with acute chest pain: the ROMICAT
AC C
461
(Rule Out Myocardial Infarction using Computer Assisted Tomography) trial. J
462
Am Coll Cardiol. 2009;53(18):1642-1650. doi:10.1016/j.jacc.2009.01.052
463
464
EP
460
TE D
457
10.
Goldstein JA, Chinnaiyan KM, Abidov A, et al. The CT-STAT (Coronary
465
Computed Tomographic Angiography for Systematic Triage of Acute Chest
466
Pain Patients to Treatment) trial. J Am Coll Cardiol. 2011;58(14):1414-1422.
467
doi:10.1016/j.jacc.2011.03.068
Page 24 of 34
ACCEPTED MANUSCRIPT 468
11.
Litt HI, Gatsonis C, Snyder B, et al. CT angiography for safe discharge of
469
patients with possible acute coronary syndromes. N Engl J Med.
470
2012;366(15):1393-1403. doi:10.1056/NEJMoa1201163 12.
Hoffmann U, Truong QA, Schoenfeld DA, et al. Coronary CT angiography
RI PT
471 472
versus standard evaluation in acute chest pain. N Engl J Med.
473
2012;367(4):299-308. doi:10.1056/NEJMoa1201161 13.
Hamilton-Craig C, Fifoot A, Hansen M, et al. Diagnostic performance and cost
SC
474
of CT angiography versus stress ECG--a randomized prospective study of
476
suspected acute coronary syndrome chest pain in the emergency department
477
(CT-COMPARE). Int J Cardiol. 2014;177(3):867-873.
478
doi:10.1016/j.ijcard.2014.10.090
479
14.
M AN U
475
Linde JJ, Hove JD, Sorgaard M, et al. Long-Term Clinical Impact of Coronary CT Angiography in Patients With Recent Acute-Onset Chest Pain: The
481
Randomized Controlled CATCH Trial. JACC Cardiovasc Imaging.
482
2015;8(12):1404-1413. doi:10.1016/j.jcmg.2015.07.015 15.
Nielsen LH, Ortner N, Norgaard BL, Achenbach S, Leipsic J, Abdulla J. The diagnostic accuracy and outcomes after coronary computed tomography
AC C
484
angiography vs. conventional functional testing in patients with stable angina
485
pectoris: a systematic review and meta-analysis. Eur Heart J Cardiovasc
486
Imaging. 2014;15(9):961-971. doi:10.1093/ehjci/jeu027
487
488
EP
483
TE D
480
16.
Ghoshhajra BB, Takx RAP, Staziaki P V, et al. Clinical implementation of an
489
emergency department coronary computed tomographic angiography protocol
490
for triage of patients with suspected acute coronary syndrome. Eur Radiol.
Page 25 of 34
ACCEPTED MANUSCRIPT 2017;27(7):2784-2793. doi:10.1007/s00330-016-4562-5
491
492
17.
Backus BE, Six AJ, Kelder JC, et al. A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol.
494
2013;168(3):2153-2158. doi:10.1016/j.ijcard.2013.01.255
495
18.
RI PT
493
Than M, Flaws D, Sanders S, et al. Development and validation of the
Emergency Department Assessment of Chest pain Score and 2 h accelerated
497
diagnostic protocol. Emerg Med Australas. 2014;26(1):34-44.
498
doi:10.1111/1742-6723.12164 19.
Meyersohn NM, Szilveszter B, Staziaki P V, et al. Coronary CT angiography in
M AN U
499
SC
496
500
the emergency department utilizing second and third generation dual source
501
CT. J Cardiovasc Comput Tomogr. 2017;11(4):249-257.
502
doi:10.1016/j.jcct.2017.03.002 20.
Raff GL, Abidov A, Achenbach S, et al. SCCT guidelines for the interpretation
TE D
503
and reporting of coronary computed tomographic angiography. J Cardiovasc
505
Comput Tomogr. 2009;3(2):122-136. doi:10.1016/j.jcct.2009.01.001
506
21.
EP
504
Cury RC, Abbara S, Achenbach S, et al. CAD-RADS(TM) Coronary Artery Disease - Reporting and Data System. An expert consensus document of the
AC C
507
Society of Cardiovascular Computed Tomography (SCCT), the American
508
College of Radiology (ACR) and the North American Society for
509 510
Cardiovascular Imaging (. J Cardiovasc Comput Tomogr. 2016;10(4):269-281.
511
doi:10.1016/j.jcct.2016.04.005
512 513
22.
Seneviratne SK, Truong QA, Bamberg F, et al. Incremental diagnostic value of regional left ventricular function over coronary assessment by cardiac Page 26 of 34
ACCEPTED MANUSCRIPT 514
computed tomography for the detection of acute coronary syndrome in patients
515
with acute chest pain: from the ROMICAT trial. Circ Cardiovasc Imaging.
516
2010;3(4):375-383. doi:10.1161/CIRCIMAGING.109.892638 23.
Staziaki PV, Kim P, Vadvala H V, Ghoshhajra BB. Medical Registry Data
RI PT
517
Collection Efficiency: A Crossover Study Comparing Web-Based Electronic
519
Data Capture and a Standard Spreadsheet. J Med Internet Res.
520
2016;18(6):e141. doi:10.2196/jmir.5576
521
24.
SC
518
Truong QA, Schulman-Marcus J, Zakroysky P, et al. Coronary CT Angiography Versus Standard Emergency Department Evaluation for Acute
523
Chest Pain and Diabetic Patients: Is There Benefit With Early Coronary CT
524
Angiography? Results of the Randomized Comparative Effectiveness
525
ROMICAT II Trial. J Am Heart Assoc. 2016;5(3):e003137.
526
doi:10.1161/JAHA.115.003137
TE D
25.
Pursnani A, Chou ET, Zakroysky P, et al. Use of Coronary Artery Calcium Scanning Beyond Coronary Computed Tomographic Angiography in the
529
Emergency Department Evaluation for Acute Chest Pain: The ROMICAT II
530
Trial. Circ Cardiovasc Imaging. 2015;8(3):e002225-e002225.
531
533 534
angiography in a large urban health care system. AJR Am J Roentgenol.
535
2013;200(1):57-65. doi:10.2214/AJR.12.8808
532
536
EP
528
AC C
527
M AN U
522
doi:10.1161/CIRCIMAGING.114.002225
26.
Cury RC, Feuchtner GM, Batlle JC, et al. Triage of patients presenting with
chest pain to the emergency department: implementation of coronary CT
27.
Uretsky S, Rozanski A, Supariwala A, et al. Clinical outcomes following a
Page 27 of 34
ACCEPTED MANUSCRIPT 537
strategy of optimized medical management and selective “downstream”
538
procedures following coronary computed tomography angiography. Int J
539
Cardiol. 2013;165(3):468-473. doi:10.1016/j.ijcard.2011.08.852 28.
2012;367(4):375-376. doi:10.1056/NEJMe1206040
541
542
Redberg RF. Coronary CT angiography for acute chest pain. N Engl J Med.
29.
RI PT
540
Dedic A, Lubbers MM, Schaap J, et al. Coronary CT Angiography for
Suspected ACS in the Era of High-Sensitivity Troponins: Randomized
544
Multicenter Study. J Am Coll Cardiol. 2016;67(1):16-26.
545
doi:10.1016/j.jacc.2015.10.045 30.
M AN U
546
SC
543
Farkouh ME, Douglas PS. The Management of Acute Chest Pain: What Lies
547
Beyond the Emergency Department Doors? J Am Coll Cardiol. 2016;67(1):27-
548
28. doi:10.1016/j.jacc.2015.09.104 31.
Board Fam Med. 2012;25 Suppl 1:S12-7. doi:10.3122/jabfm.2012.02.110212
550
32.
Katz DA, Williams GC, Brown RL, et al. Emergency physicians’ fear of
EP
551
van Weel C, Schers H, Timmermans A. Health care in the Netherlands. J Am
TE D
549
malpractice in evaluating patients with possible acute cardiac ischemia. Ann
553
Emerg Med. 2005;46(6):525-533. doi:10.1016/j.annemergmed.2005.04.016
554 555
33.
AC C
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Badri M. Medical malpractice litigation: a fellow’s perspective. J Am Coll
Cardiol. 2014;64(4):418-419. doi:10.1016/j.jacc.2014.06.013
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10. Figure legends 10.1.
Figure 1. Typical flow of potential ACS patients from the ED to
coronary CTA ACS - Acute Coronary Syndrome; ED - Emergency Department; CTA - Computed
562
Tomographic Angiography; PA - Physician Assistant; ECG - Electrocardiogram;
563
STEMI - ST-segment Elevation Myocardial Infarction; NSTEMI - Non-ST segment
564
Elevation Myocardial Infarction
565
* An additional set of [Troponin] could be assessed
566
◊ Inpatient floor options are; monitored bed on internal medicine floor, cardiac acces-
567
/ 'step-down unit' (SDU) or coronary care unit (CCU)
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Typical flow
Atypical flow
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10.2.
Table 1. Subject Characteristics
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10.3.
Figure 2. Coronary CTA results and following diagnostic work-ups
CTA - Computed Tomography Angiography; SCRST - Secondary Cardiac Risk
574
Stratifying Test; ICA - Invasive Coronary Angiography; SPECT - Single-Photon
575
Emission Computed Tomography; ETT - Exercise Tolerance Testing
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10.4.
Figure 3.
69 y/o male whom presented to the emergency department with 2 days of worsening
579
left and mid chest pain (and negative initial biomarkers and ECG). CTA showed
580
moderate left main stenosis (arrow) and mid left anterior descending artery stenoses
581
(arrowheads), as well as severe disease in small marginal branches and the distal
582
RCA (not shown). After confirmation by invasive coronary angiography (right image),
583
he underwent successful coronary artery bypass grafting.
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10.5.
Figure 4.
59 y/o woman with chief complaint of chest pain and dizziness: CTA demonstrates a
587
chronic total occlusion of the proximal RCA (panel 4A, arrowheads), with left-to right
588
and right-to-right collaterals (panel 4A, arrow). CT also depicted an inferior basal
589
aneurysm, seen here on systolic short axis and 2-chamber 8 mm thick mulitplanar
590
reformatted images (panels 4B & 4C, arrowheads) which were corroborated by
591
subsequent cardiac ultrasound performed the same day (panel 4D, arrowheads).
592
The patient was discharged on maximal medical therapy; after 3 months without
593
resolution of symptoms, she underwent ICA that showed unchanged chronic total
594
occlusion of the proximal RCA (panel 4E, arrowheads) and the left-to right and right-
595
to-right collaterals (panel 4F, arrow) and received successful percutaneous coronary
596
intervention on the right coronary artery, with resolution of symptoms.
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598
Appendix. CAD-RADS reporting and data system for patients
presenting with stable chest pain21
599
The CAD-RADS classification should be applied on a per-patient basis for the
601
clinically most relevant (usually highest-grade) stenosis.
602
All vessels greater than 1.5 mm in diameter should be graded for stenosis severity.
603
CAD-RADS will not apply for smaller vessels (<1.5 mm in diameter).
604
MODIFIERS: If more than one modifier is present, the symbol “/” (slash) should
605
follow each modifier in the following order:
606
First: modifier N (non-diagnostic)
607
Second: modifier S (stent)
608
Third: modifier G (graft)
609
Fourth: modifier V (vulnerability)
610
a
CAD - coronary artery disease
611
b
CAD-RADS 1 - This category should also include the presence of plaque with
612
positive remodeling and no evidence of stenosis
613
c
Guideline-directed care per ACC Stable Ischemic Heart Disease Guidelines
614
d
ICA - invasive coronary angiography
615
(Reprinted, by permission from Elsevier, from Cury RC, Abbara S, Achenbach S, et
616
al. CAD-RADS(TM) Coronary Artery Disease - Reporting and Data System. An
617
expert consensus document of the Society of Cardiovascular Computed
618
Tomography (SCCT), the American College of Radiology (ACR) and the North
619
American Society for Cardiovascular Imaging. J Cardiovasc Comput Tomogr.
620
2016;10(4):269-281. doi:10.1016/j.jcct.2016.04.005)
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ACCEPTED MANUSCRIPT Further Cardiac Investigation
Degree of maximal coronary stenosis Interpretation
a
CAD-RADS 0
0% (No plaque or stenosis)
Documented absence of CAD
None
CAD-RADS 1
1-24% - Minimal stenosis or plaque b with no stenosis
Minimal non-obstructive CAD
None
Management - Reassurance. Consider non- atherosclerotic causes of chest pain - Consider non- atherosclerotic causes of chest pain - Consider preventive therapy and risk factor modification
25-49% Mild stenosis
Mild non-obstructive CAD
None
CAD-RADS 3
50-69% stenosis
Moderate stenosis
Consider functional assessment
CAD-RADS 4
A - 70-99% stenosis or
Severe stenosis
A: Consider ICA or functional assessment
B - Left main >50% or 3-vessel obstructive (≥70%) disease
d
B: ICA is recommended
100% (total occlusion)
Total coronary occlusion
Consider ICA and/or viability assessment
CAD-RADS N
Non-diagnostic study
Obstructive CAD cannot be excluded Additional or alternative evaluation may be needed
- Consider symptom-guided anti-ischemic and preventive pharmacotherapy as well as risk factor modification per guideline-directed carec - Other treatments (including options of revascularization) c should be considered per guideline-directed care
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CAD-RADS 5
- Consider non- atherosclerotic causes of chest pain - Consider preventive therapy and risk factor modification, particularly for patients with non- obstructive plaque in multiple segments - Consider symptom-guided anti-ischemic and preventive pharmacotherapy as well as risk factor modification per guideline-directed carec - Other treatments should be considered per guidelinec directed care - Consider symptom-guided anti-ischemic and preventive pharmacotherapy as well as risk factor modification per guideline-directed carec - Other treatments (including options of revascularization) should be considered per guideline-directed carec
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CAD-RADS 2
ACCEPTED MANUSCRIPT ±10.8 (3.8%) (18.2%) (36.2%) (27.3% (11.7%) (2.2%) (0.5%)
1061
(55.4%)
1293 202 73 348
(67.5%) (10.5%) (3.8%) (18.2%)
1598 199 119 29.6 224 518 740
(83.4%) (10.4%) (6.2%) ±6.3 (11.7%) (27.0%) (38.6%)
SC
52.9 73 348 694 524 225 43 9
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Age mean ≥ 18 - 34 years 35 - 44 years 45 - 54 years 55 - 64 years 65 - 74 years 75 - 84 years ≥ 85 years Gender Male Race Caucasian African-American Asian Other / Unknown Ethnicity Not hispanic/Latino Hispanic/Latino Unknown Body mass index (BMI) Diabetes Mellitis Dyslipidemia Hypertension
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N=1916
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Demographics
S1934-5925(18)30123-0
DOI:
10.1016/j.jcct.2018.10.005
Reference:
JCCT 1146
To appear in:
Journal of Cardiovascular Computed Tomograph
Received Date: 22 May 2018 Revised Date:
15 September 2018
Accepted Date: 2 October 2018
Please cite this article as: Verheij VA, Scholtz J-E, Meyersohn NM, Parry BA, Hoffmann U, Ghoshhajra BB, Nagurney JT, Secondary cardiac risk stratifying tests after coronary computed tomography angiography in emergency department patients, Journal of Cardiovascular Computed Tomograph (2018), doi: https://doi.org/10.1016/j.jcct.2018.10.005. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Secondary Cardiac Risk Stratifying Tests after Coronary Computed
2
Tomography Angiography in Emergency Department Patients
3
Autohors
4
Vincent A. Verheij, M.D.a
[email protected]
5
Jan-Erik Scholtz, M.D.b
[email protected]
6
Nandini M. Meyersohn, M.D.b
[email protected]
7
Blair A. Parry, B.A.c
[email protected]
8
Udo Hoffmann, M.D., M.P.H.b
[email protected]
9
Brian B. Ghoshhajra, M.D., M.B.A.b*
[email protected]
10
John T. Nagurney, M.D., M.P.H.a#
[email protected]
11
Affiliations
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a. Department of Emergency Medicine
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Massachusetts General Hospital & Harvard Medical School
14
55 Fruit Street, Boston, Massachusetts, 02114, USA
15
Phone: +1 617-726-7623
b. Cardiac MR PET CT Program Department of Radiology and Division of Cardiology
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Massachusetts General Hospital & Harvard Medical School
18
55 Fruit Street, Boston, Massachusetts, 02114, USA
19 20
c. Department of Emergency Medicine and Division of Research
21
Massachusetts General Hospital
22
5 Emerson Place, Boston, Massachusetts, 02114, USA
23
*
Co-senior author
# Corresponding author
ACCEPTED MANUSCRIPT Conflicts of interest
25
This research did not receive any specific grant from funding agencies in the public,
26
commercial or not-for-profit sectors.
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ACCEPTED MANUSCRIPT
Secondary Cardiac Risk Stratifying
2
Tests after Coronary Computed
3
Tomography Angiography in
4
Emergency Department Patients
5
Abstract
6
Background
7
Several large trials demonstrated that coronary computed tomography angiography
8
(CTA) in a triage strategy could lead to increased secondary cardiac risk stratifying
9
testing (SCRST). Whether this is true for routine clinical care remains unclear. We
10
measured SCRSTs after coronary CTA was implemented in our emergency
11
department (ED) practice by CTA result, and if locally existing management
12
recommendations for a structured post CTA diagnostic strategy were followed.
13
Methods
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This single site retrospective cohort study included all our ED patients who received
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coronary CTA between October 1, 2012 and September 30, 2016. SCRST’s
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included functional cardiac tests and invasive coronary angiography (ICA),
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performed during the ED coronary CTA visit or related admission.
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ACCEPTED MANUSCRIPT Results
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A total of 1916 subjects were included with a mean age of 52.9 ±10.8 years. Of their
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coronary CTAs, 179 were positive (severe stenosis, occlusion or ventricular wall
21
motion abnormalities; 9.3%), 105 intermediate (moderate stenosis; 5.5%), 1611
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negative (no to mild obstructive CAD; 84.1%) and 21 non-diagnostic (1.1%).
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SCRSTs were performed in 237 (overall 12.4%, noninvasive in 5.6%, ICA in 6.7%).
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After positive coronary CTA, 73.7% of subjects received SCRSTs. For intermediate,
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negative and non-diagnostic CTAs this was 72.4%, 1.1% and 47.6% respectively.
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Management conformed to local management recommendations in 96.2% of cases.
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Conclusion
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In spite of previous trials, rates of secondary cardiac risk stratifying tests after routine
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clinical ED coronary CTA are low, especially in patients with negative coronary CTA.
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Structured management guidelines for post coronary CTA, and adherence to these
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guidelines, appear essential.
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Key words
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Acute Chest Pain; Acute Coronary Syndrome; Coronary CTA; Downstream Testing;
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Secondary Cardiac Risk Stratifying Tests;
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Several large controlled trials demonstrated that coronary CTA in a triage strategy
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could lead to increased downstream cardiac testing. Using data of four years of
39
clinical coronary CTA use, this study retrospectively investigated whether this is true
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when ED coronary CTA is implemented in routine clinical ED practice.
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ACCEPTED MANUSCRIPT Abbreviations
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ED – Emergency department
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ACS – Acute coronary syndrome
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CTA – Computed tomography angiography
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CAD – Coronary artery disease
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SCRST – Secondary cardiac risk stratifying test
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ETT – Exercise tolerance test
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MPI – Myocardial perfusion imaging
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SPECT – Single-photon emission computed tomography
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CMR – Cardiovascular magnetic resonance imaging
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PET – Positron emission tomography
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hs-cTn – High sensitive cardiac troponin
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eGFR – Estimated glomerular filtration rate
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ECG – Electrocardiography
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PA – Physician Assistant
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SDU – Step down unit
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CCU – Coronary care unit
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CAD-RADS – Coronary artery disease reporting and data system
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ICA – Invasive coronary angiography
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VWMA – Ventricular wall motion abnormality
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TTE – Transthoracic echocardiogram
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TEE – Transesophageal echocardiogram
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MRI – Magnetic resonance imaging
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PCP – Primary care physician
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AMA – Against medical advise
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ACCEPTED MANUSCRIPT 1. Introduction
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Nonspecific chest pain is the second most frequent first-listed medical diagnosis for
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emergency department (ED) visits in the US with an incidence increase of 26% from
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2006 to 2014.1 Coronary atherosclerosis however showed the greatest decrease
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amongst first-listed medical diagnosis with 34% over the same period.1 Hence rapid
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and efficient triage strategies for patients with possible acute coronary syndromes
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(ACS) are crucial.
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Recently, coronary computed tomography angiography (coronary CTA)2 has
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been added to the diagnostic armamentarium for low- to intermediate-risk ACS
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patients.3 This new risk stratification weapon allows for the noninvasive visualization
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of obstructive coronary plaques or stenoses, and enables assessment of valves and
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regional resting ventricular wall motions.4–6 Although coronary CTA evaluates the
79
anatomical aspects of coronary artery disease (CAD), as opposed to classic
80
functional tests, multiple studies have shown that if coronary CTA is negative for
81
significant luminal narrowing, the likelihood of ACS is very low.7–9 In addition, use of
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coronary CTA has been shown to result in reduction in length of stay and increased
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ED discharge rates with exceptionally low major adverse clinical events.10–14
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Nonetheless, several controlled trials noted that a potential drawback of ED
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coronary CTA implementation is increased downstream testing and costs of
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diagnostic evaluation.12–15 Whether this is true for post CTA tests with routine clinical
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use however is unclear. The aim of this study was to measure secondary cardiac risk
88
stratifying testing(SCRST) in all our ED patients who had received coronary CTA as
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part of routine clinical care. SCRSTs were included if they occurred during the visit
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when ED coronary CTA was performed or during a related admission (including
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those to the ED observation unit). Our secondary aim was to measure adherence to
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locally designed management recommendations to evaluate their effect on
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downstream testing rates.16
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2. Methods 2.1. Study Design We performed a single site, retrospective cohort study using data from our
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consecutive case coronary CTA registry. This is a registry of all coronary CTAs that
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are performed on adult patients at an ED visit, or their related admission to the ED
100
observation unit, as part of routine clinical care. It also includes all other cardiac tests
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that occurred during that visit or related admission, and has previously been
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approved by our institutional review board. Informed consent was waived due to the
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retrospective design of the study.
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2.2. Setting and Location
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The setting was the ED of an American academic medical center with an average
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annual ED patient volume of 106,000. In this tertiary hospital, where two observation
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units totaling 34 beds are part of the ED, coronary CTA was implemented into
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routine clinical care in October 2012 and is performed on two dual-source CT-
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scanners, one of which is located in the ED. Purely based on their preference,
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emergency physicians were free to choose either this anatomical assessment for
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primary cardiac risk stratification, or conventional stress testing, including exercise
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tolerance testing without imaging (ETT), stress-induced myocardial perfusion
113
imaging (MPI/SPECT) or stress ultrasound testing (dobutamine or exercise
114
echocardiogram). Stress myocardial perfusion cardiovascular magnetic resonance
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imaging (CMR) and positron emission tomography (PET) are not commonly
116
performed in our hospital on potential ACS ED patients. No advanced diagnostic
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pathways such as the HEART
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or EDACS
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time of intake for this study, nor were high-sensitivity cardiac troponin (hs-cTn)
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assays available at the time. Eligible criteria for coronary CTA did not restrict patients based on heart rate,
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rhythm or body habitus but recommended relative contraindications were known
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CAD or prior revascularizations, impaired renal function (eGFR < 60mL/min/1.73m2),
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contrast-allergy and serum biomarker levels or ECG changes suggestive of
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myocardial ischemia.
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All scans were physician-supervised during gradually expanded operating
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hours, with protocols as previously published.16,19 A non-contrast coronary calcium
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scan was obtained in all patients but contrast-enhanced scans were performed
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regardless of coronary calcium burden. Unless contraindicated, 600 mcg of
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sublingual nitroglycerin was administered at least 5 minutes prior to an arterial bolus-
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timed contrast-enhanced CTA. Prospective ECG triggering, with widening of the
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acquisition window to include end-systole and late-diastole, or retrospective ECG
132
gating was performed depending on heart rate and rhythm, to allow for functional
133
assessment in nearly all patients, as detailed.19 Board certified and subspecialty-
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trained cardiovascular radiologists interpreted images in real time and results were
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immediately called back to the referring ED providers to facilitate a dialogue between
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the reader and referring provider on appropriate further management. Decision
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makers in the ED were residents or physician assistants (PA) and in the ED
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Observation Units nurse practitioners or PAs. SCRSTs may not have been ordered
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by the provider who originally ordered the coronary CTA, but all decision makers
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were familiar with the same post CTA management recommendations and were
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supervised by board certified or board eligible emergency physicians at any time.
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ECGs were reviewed by ED attending physicians in real time.
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ACCEPTED MANUSCRIPT ED patients were typically discharged home, admitted to an ED Observation
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Unit for further evaluation, admitted to an Internal Medicine floor, a general
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cardiology floor, a step-down unit (SDU) or a coronary care unit (CCU), depending
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on the results of their ED evaluation. Figure 1 shows the typical flow of potential ED
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ACS patients through the ED, their paths to the provider’s preferred ischemic risk
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stratifying test and possible subsequent testing.
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2.3. Study Population
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Our research involved a consecutive registry of ED patients in whom coronary CTA
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was used as a clinical risk stratifying test. Patients were included if their ED coronary
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CTA was performed between October 1, 2012 and September 30, 2016. Excluded
153
were those with a documented elevated Troponin-T ≥ 0.03 ηg/mL prior to their
154
coronary CTA, because they would normally not receive coronary CTA due to their
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high likelihood of ACS. If two attempts to scan were made for the same patient (e.g.
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due to an IV-catheter problem with the first) only the one with the completed scan
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was included.
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Strict guidelines for patient management after coronary CTA did not exist at the
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beginning of the registry given that the early Society of Cardiovascular Computerized
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Tomography guidelines for coronary CTA reporting did not include treatment
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guidelines.20 However, a multidisciplinary site “task force” was originally created to
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lay out non-binding local management recommendations based on existing
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literature. ED providers were informed of these management recommendations by
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presentations at staff meetings and didactic sessions, through posts on the
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Emergency Medicine intranet and by discussions with the CTA reviewers when
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results were verbally reported.
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ACCEPTED MANUSCRIPT Towards the end of our study period, the Coronary Artery Disease Reporting
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and Data System (CAD-RADS, Appendix)21 definitions and recommendations were
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published. Since they were identical to our traditional site thresholds of stenosis
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grading and management recommendations, they then became standard practice.
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Specific recommendations for post coronary CTA management were as follows; no
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further cardiac investigations should be performed after negative coronary CTA
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(CAD-RADS 0-2); a physiologic cardiac risk stratification test should be performed
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after intermediate (CAD-RADS 3) or non-diagnostic scans (CAD-RADS “N”); and
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cardiology consultation should be obtained for patients with positive coronary CTA
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(defined as CAD-RADS 4-5 or any ventricular wall motion abnormalities(VWMA)).
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VWMAs are not covered by the CAD-RADS paradigm but have been shown to have
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incremental diagnostic yield and were therefore believed to warrant cardiology
180
consultation.22 It was further recommended that exceptions should be made on a
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per-patient basis (e.g. coronary CTA resulting in CAD-RADS modified “V” –
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vulnerable plaque). No specific recommendations were made for non-risk stratifying
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cardiac tests in the face of an abnormal coronary CTA.
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2.5. Definition of Primary Outcome All cardiac tests performed after coronary CTA but during the same ED visit or
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related admission were counted and scored risk stratifying or non-risk stratifying
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tests. SCRSTs were any additional cardiac risk stratifying tests; ETT, MPI/SPECT,
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stress ultrasound or invasive coronary angiography (ICA). These subsequent cardiac
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tests were then categorized by the results of the coronary CTA.
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2.6. Definition of Secondary Outcome
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Providers were considered to have followed local management recommendations if
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194
as phone discussions with cardiologists, during the ED coronary CTA visit or related
195
admission. Cardiac tests that do not increase myocardial demand (e.g. transthoracic
196
echocardiogram (TTE), transesophageal echocardiogram (TEE), resting cardiac MRI
197
and FDG-18 study (cardiac PET scan) were also in our registry, but were excluded
198
from our primary analysis as they do not stratify for cardiac ischemic risks. These
199
cardiac non-risk stratifying tests were reviewed and described separately. They were
200
considered appropriate if the coronary CTA demonstrated cardiac abnormalities, if
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the cardiac imager recommended a non-stress echo or if the ECG was abnormal.
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2.7. Data Collection, Management and Analysis
Data from our online registry (Research Electronic Data Capture tool (REDCap)
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v6.15.11 – Vanderbilt University, Nashville, TN) were downloaded onto a Microsoft
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Excel spreadsheet (Microsoft Office Professional Plus 2007 v12.0.6765.5000 –
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Microsoft Corporation, Redmond, WA) and used for analysis. More specifics about
207
the validated data entry methods used have been previously published.16,23 Coronary
208
CTA results and secondary cardiac tests were reviewed by the principal investigator,
209
the registry keeper, the senior cardiac imager and the senior investigator.
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Adjudication was made by consensus. Descriptive statistics were used with means,
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medians, percentages, and when appropriate, 95% confidence intervals or standard
212
deviations.
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3. Results 3.1. Subject characteristics A total of 1924 ED coronary CTA records were created during the four year intake
217
period of our study. One patient had two records from the same ED visit of which the
218
first was excluded because the CTA was aborted after the IV catheter malfunctioned
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and therefore had to be re-ordered the following day. Seven other records were
220
excluded because of elevated initial serum cardiac biomarkers. The mean age of the
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included 1916 patients was 52.9 ±10.8 years and 55.4% were male. These and other
222
detailed baseline subject characteristics are listed in Table 1.
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3.2. Secondary Cardiac Risk Stratifying Testing and Adherence to Recommendations.
Figure 2 demonstrates all subjects’ final coronary CTA results and lists SCRSTs by
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corresponding management recommendations. Overall, 237 subjects (12.4%; 95%
227
CI 10.9% to 13.8%) received one or more noninvasive SCRSTs (5.6%) or ICA
228
(6.8%) during their ED coronary CTA visit or related admission. Five subjects
229
received their SCRST from the ED, 66 from the ED observation unit and 166 from
230
other inpatient floors. Subsequent diagnostic steps followed local management
231
recommendations in 1844 (96.2%; 95% CI 95.4% to 97.1%).
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A total of 179 (9.3%; 95% CI 8.0% to 10.6%) subjects had positive coronary
233
CTA (CAD-RADS 4-5 or VWMA). In 146 (81.6%) this was due to actual obstructive
234
CAD and in 33 (18.4%) this was solely due to VWMAs without the presence of
235
obstructive CAD (CAD-RADS 0-3). Of these 179 positive coronary CTA subjects,
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165 (92.2%; 95% CI 91.0 to 93.4%) received cardiology consultation, resulting in 132
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(64.8%) (Figure 3) and physiologic SCRSTs only in 25 (15.2%) cases. Thirty-three
239
(20.0%) consulted subjects received no SCRSTs at all (Figure 4). Fourteen (7.8%) subjects with positive coronary CTA did not receive
241
cardiology consultation. Eight had only regional ventricular wall motion abnormalities
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and were advised to follow up with their primary care provider (PCP) and another
243
three left against medical advice(AMA). One of the remaining three subjects received
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an SCRST making the total of positive subjects with SCRSTs 133 (74.3%; 95% CI
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72.3% to 76.3%).
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Coronary CTA was intermediate in 105 (5.5%; 95% CI 4.5% to 6.5%) subjects
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of which 76 (72.4%; 95% CI 70.4% to 74.4%) received SCRSTs, with 21 (20.0%)
248
receiving at least ICA. Of the 29 (27.6%) subjects that did not receive SCRSTs, 19
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(65.5%) were seen by a cardiologist, eight during the same ED visit or related
250
admission and 11 within a month of the index visit. Four subjects were scheduled for
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an SCRST but left prior to imaging. The remaining subjects underwent follow up care
252
elsewhere or were admitted for other reasons.
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Together, 1611 (84.1%; 95% CI 82.4% to 85.7%) coronary CTAs were
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negative of which eighteen (1.1%, 95% CI 0.6% to 1.6%) received SCRSTs. In six
255
cases, SCRSTs were recommended by a cardiologist, in another two were concerns
256
about ECG abnormalities, one SCRST was recommended per CTA result and one
257
coronary CTA result was misinterpreted by ED providers. All SCRSTs after negative
258
coronary CTA were negative for ischemia, except one which demonstrated either an
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artifact or a very small territory of mild anterolateral ischemia without evidence of
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infarction.
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3.3. Non-diagnostic Coronary CTA Twenty-one (1.1%; 95% CI 0.6% to 1.6%) subjects received non-diagnostic coronary
263
CTA. In two, obstructive disease could not be excluded because the coronary CTA
264
was aborted after allergic reactions to the test bolus of iodine. Other reasons for
265
limited evaluation were motion artifacts (7), suboptimal contrast opacification (5),
266
body habitus (4) or extensive coronary artery calcification (3). Eleven of the non-
267
diagnostic coronary CTAs (52.4%; 95% CI 50.1% to 54.6%) were not followed by
268
SCRSTs, of which four were told to follow up with their PCP. Another four had no
269
luminal narrowing in the visualized segments and one received cardiology
270
consultation.
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3.4. Cardiac Non-Risk Stratifying Tests
A total of 75 (3.9%; 95% CI 3.0% to 4.8%) subjects received cardiac non-risk
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stratifying tests after coronary CTA. Seventy-three (97.3%) received TTE, one
274
(1.3%) TEE and one (1.3%) had both. Most (n=67, 89.3%) were performed in
275
subjects with abnormal coronary CTA (n=4), with non-coronary pathologic findings
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(n=22), with ECG abnormalities (n=1) or with a combination of the above (n=40) but
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in eight (10.7%) cases we could not find any indication for the performed
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ultrasounds.
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4. Discussion 4.1. Secondary cardiac risk stratifying testing after ED coronary CTA In the ED of an academic medical center that was early to embrace clinical coronary
283
CTA to rule out ACS, routine CTA use led to downstream testing in 12.4% of
284
patients. This relatively low number includes noninvasive testing (5.6%), invasive
285
coronary angiography (6.1%) and both (0.6%) in a population with 84.1% negative
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coronary CTA results (CAD-RADS 0-2).
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Two large studies from the early coronary CTA trial-era demonstrated increased
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overall downstream testing in their coronary CTA-arm compared to standard of
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care.11,12 In the multicenter ACRIN-PA trial11, 17.7% of all potential ACS ED subjects
291
randomly assigned to coronary CTA underwent SCRSTs, and the rate of
292
downstream testing during the similar multicenter ROMICAT-II trial12 was 23.2%.
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From these preliminary trials, it would appear as if the advantage of coronary CTA,
294
i.e. the ability to identify pre-symptomatic lesions, results in more downstream testing
295
through pursuit of the exact ischemic burden of visualized non-obstructing plaques.
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Our total downstream testing rate of 12.4% however, is considerably lower,
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despite seemingly similar populations. We were unable to report, and thus compare
298
ACS rates as complete 60-day follow-up was ascertained in only the first 550
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subjects. However, using abnormal result percentages as a proxy for prevalence of
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ACS demonstrates how our population appears to have been similar to ACRIN-PA
301
and ROMICAT-II24. Our percent of abnormal CTAs (intermediate, positive or non-
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diagnostic) was 15.9 compared to 21.4% in the ACRIN-PA study and 16.6% in the
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ROMICAT-II study. And while for the same reason we could not report on tests
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hospitalization, prior experience from the ROMICAT-II trial demonstrated that
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SCRSTs are primarily performed during the ED coronary CTA visit or related
307
admission. (Of 139 SCRSTs performed on 473 ED coronary CTA subjects, 83.5%
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was performed during the ED coronary CTA visit or related admission.25) Hence, our
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lower downstream testing rate is not likely related to disease prevalence or lack of
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follow-up.
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Our hypothesis is that our SCRST rate reflects a learning curve at our
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institution. After careful implementation of coronary CTA into our ED practice
313
(demonstrated
314
recommendations of 96.2%) our SCRST usage presumably reduced with growing
315
clinical practice. While only about a dozen ED coronary CTAs were ordered during
316
the first few months of its implementation, coronary CTA quickly gained popularity.
317
We currently perform them on a daily basis, allowing us to include almost 2000
318
subjects in 4 years. This increased clinical use and experience suggests an ample
319
‘real world’ experience over years. ACRIN-PA and ROMICAT-II on the other hand
320
had intake periods prior to November 2011, when providers had little or no
321
antecedent experience with coronary CTA patient management. Our experience is
322
further corroborated by the fact that our SCRST rate approaches the 10.6% of
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SCRSTs performed in subjects with well established, standards of care during
324
ROMICAT-II. In addition, the rate of ICA in our study was also lower than reported in
325
ROMICAT-II (6.8% vs. 10.8%), suggesting increasing confidence on the part of
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providers that coronary CTA accurately identifies non-obstructive coronary
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atherosclerotic plaque.
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after implementation of coronary CTA in ED practice.26,27 In most groups, SCRST
330
usage was fairly similar, but only 1.1% of the vast majority of our population was sent
331
to obtain SCRSTs versus Cury’s 3.2% and Uretsky’s 15.5% of negative cases. Thus,
332
fears of unnecessary “layering” of cardiac tests do not seem justified.28 Nevertheless,
333
the latter studies were also reported early in the clinical ED coronary CTA era,
334
explaining their defensive approaches. Since then, data have accumulated that
335
consistently demonstrate the powerful negative predictive values of coronary CTA to
336
identify patients safe for discharge21, encouraging physicians to hold back on
337
additional testing.
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Interestingly, with growing coronary CTA experience around the globe, a
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recent trail in fact demonstrated how downstream testing decreased with coronary
340
CTA.29 The Dutch BEACON study, a randomized multicenter trial investigating
341
coronary CTA effectiveness, did not show reduction of length of stay (presumably
342
due to recent implementation of hs-Troponins) and was underpowered to report a
343
difference in identification of significant CAD requiring coronary revascularization.
344
However, it did demonstrate significantly lower evaluation costs (34%) and less
345
subsequent outpatient testing in their CTA arm (10% vs. 26%). Numerous factors
346
clearly limit result comparability, let alone generalizability of these European results
347
to American medical centers30, but the BEACON results appear promising. While
348
including patients with mildly elevated troponins, in a health care system like the
349
European’s where very low-risk patients are screened out of EDs by a general
350
practitioner or by ambulance triage31, downstream testing did not increase. Then
351
again, this study was performed in a region where medical workup may not be as
352
defensive as the American, due to less fear of litigation and fewer limitations in
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testing within 48-72h of the index ED visit as opposed to work-up during the index
355
visit or related admission. But with all that aside, this trial could suggest that coronary
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CTA has the potential to reduce cardiac risk stratifying test ‘shingling’.
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4.3. Evaluation
Our contribution is to show that use of coronary CTA in standard clinical practice
359
should not lead to more downstream testing. Nonetheless, half of a small group of
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non-diagnostic coronary CTA subjects did not receive SCRSTs as was
361
recommended by our guidelines. Fortunately, most of these subjects received at
362
least cardiology consultation or were told to follow up with their primary care
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provider. Future research projects could look into the value and yield of SCRSTs in
364
non-diagnostic coronary CTAs without obstructive CAD in the segments visualized.
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Also, for positive coronary CTA subjects (CAD-RADS 4-5 or VWMA) who failed to
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receive cardiology consultation (n=14; 7.8%) and subjects with intermediate coronary
367
CTA (CAD-RADS 3) without SCRSTs (n=29; 27.6%), our conjecture is that
368
appropriate care has still taken place. The majority of these subjects with positive
369
coronary CTA had only VWMAs without significant obstructive CAD and the majority
370
of the subjects with intermediate outcome CTA received cardiology consultation.
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This suggests that our recommendation to pursue intermediate coronary CTA with
372
an SCRST may have competed with a seasoned cardiologists’ opinion on optimal
373
management. Nevertheless, a large number of subjects with positive coronary CTA
374
received no SCRST after their cardiology consultation. Consultation during the ED
375
visit or related admission led to further testing in 80.0%, with ICA in 64.8%.
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number would appear to have been unnecessary. Future research projects could
380
determine whether this additional cardiac imaging changed clinical outcomes or
381
provided additional information to an anatomy assessing coronary CTA.
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4.4. Limitations
This study included a large population from a highly specialized center with
384
distinct ED coronary CTA experience. Hence, our results may not be generalizable
385
to other EDs. Additionally, we did not report on comparing risk stratifying strategies,
386
i.e. stress testing, to put our data in perspective. This study was merely a descriptive
387
study of practice. As it is not a safety study, it does not provide answers on who
388
should receive cardiac risk stratification or on what tests to use. The choice of
389
coronary CTA for cardiac risk stratification solely depended on provider preferences,
390
as there never were protocols on when to use coronary CTA. This limited the
391
discussion of factors influencing the decision to order a coronary CTA in the first
392
place. We also did not compare SCRSTs individually, as their availabilities are highly
393
center-specific and we had no recommendations on which SCRST to use
394
specifically. This choice was also left to the discretion of the physician.
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Also, although we used a consecutive case registry, data were gathered
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retrospectively, disallowing us from inferring why certain clinical actions were taken.
397
The value of SCRSTs performed in conjunction with coronary CTA, and whether
398
they added clinical value, could not be determined. Finally, ACS rates and outpatient
399
testing for our population could not be directly determined. Instead, without a
400
universally accepted standard to calculate a populations’ risk for ACS, we used our
401
abnormal coronary CTA percentage as a proxy for ACS prevalence.
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Coronary CTA as a first line tool to evaluate patients with acute chest pain in a busy
405
ED does not necessarily lead to increased downstream testing. In our tertiary
406
medical center, rates of downstream tests, especially for patients with negative
407
coronary CTA are lower than previous trials reported. A high adherence rate to
408
dedicated management guidelines for post coronary CTA may explain this.
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6. Appendix
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Copy of CAD-RADS Classification
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ACCEPTED MANUSCRIPT 7. Acknowledgements
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The authors gratefully acknowledge the enthusiastic support in literature analysis of
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Mrs. Martha E. Stone, M.S., coordinator for Research & Reference of the Treadwell
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Library. We would also like to acknowledge the staffs of our Department of
417
Emergency Medicine and Emergency Cardiac CTA program.
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8. Funding
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This research did not receive any specific grant from funding agencies in the public,
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commercial or not-for-profit sectors.
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9. References
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1.
Moore BJ, Stocks C, Owens PL. Trends in emergency department visits, 2006–2014. Healthc Cost Util Proj Stat Briefs. 2006;Statistica(December
425
2012):893-908. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb227-
426
Emergency-Department-Visit-Trends.pdf.
427
2.
RI PT
424
Weigold WG, Abbara S, Achenbach S, et al. Standardized medical terminology for cardiac computed tomography: a report of the Society of Cardiovascular
429
Computed Tomography. J Cardiovasc Comput Tomogr. 2011;5(3):136-144.
430
doi:10.1016/j.jcct.2011.04.004 3.
M AN U
431
SC
428
Wolk MJ, Bailey SR, Doherty JU, et al.
ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013
433
multimodality appropriate use criteria for the detection and risk assessment of
434
stable ischemic heart disease: a report of the American College of Cardiology
435
Foundation Appropriate Use Criteria Task Forc. J Card Fail. 2014;20(2):65-90.
436
doi:10.1016/j.cardfail.2013.12.002 4.
AC C
of coronary artery stenosis in individuals without known coronary artery
439
disease: results from the prospective multicenter ACCURACY (Assessment by
440
Coro. J Am Coll Cardiol. 2008;52(21):1724-1732.
441
doi:10.1016/j.jacc.2008.07.031
442
444
Budoff MJ, Dowe D, Jollis JG, et al. Diagnostic performance of 64multidetector row coronary computed tomographic angiography for evaluation
438
443
EP
437
TE D
432
5.
Meijboom WB, Meijs MFL, Schuijf JD, et al. Diagnostic accuracy of 64-slice computed tomography coronary angiography: a prospective, multicenter,
Page 23 of 34
ACCEPTED MANUSCRIPT 445
multivendor study. J Am Coll Cardiol. 2008;52(25):2135-2144.
446
doi:10.1016/j.jacc.2008.08.058
447
6.
Shapiro MD, Dodd JD, Kalva S, et al. A comprehensive electrocardiogramgated 64-slice multidetector computed tomography imaging protocol to
449
visualize the coronary arteries, thoracic aorta, and pulmonary vasculature in a
450
single breath hold. J Comput Assist Tomogr. 2009;33(2):225-232.
451
doi:10.1097/RCT.0b013e31817c12b1 7.
SC
452
RI PT
448
Hollander JE, Litt HI, Chase M, Brown AM, Kim W, Baxt WG. Computed tomography coronary angiography for rapid disposition of low-risk emergency
454
department patients with chest pain syndromes. Acad Emerg Med.
455
2007;14(2):112-116. doi:10.1197/j.aem.2006.09.051
456
8.
M AN U
453
Cury RC, Feutchner G, Pena CS, Janowitz WR, Katzen BT, Ziffer JA. Acute chest pain imaging in the emergency department with cardiac computed
458
tomography angiography. J Nucl Cardiol. 2008;15(4):564-575.
459
doi:10.1016/j.nuclcard.2008.05.006 9.
Hoffmann U, Bamberg F, Chae CU, et al. Coronary computed tomography angiography for early triage of patients with acute chest pain: the ROMICAT
AC C
461
(Rule Out Myocardial Infarction using Computer Assisted Tomography) trial. J
462
Am Coll Cardiol. 2009;53(18):1642-1650. doi:10.1016/j.jacc.2009.01.052
463
464
EP
460
TE D
457
10.
Goldstein JA, Chinnaiyan KM, Abidov A, et al. The CT-STAT (Coronary
465
Computed Tomographic Angiography for Systematic Triage of Acute Chest
466
Pain Patients to Treatment) trial. J Am Coll Cardiol. 2011;58(14):1414-1422.
467
doi:10.1016/j.jacc.2011.03.068
Page 24 of 34
ACCEPTED MANUSCRIPT 468
11.
Litt HI, Gatsonis C, Snyder B, et al. CT angiography for safe discharge of
469
patients with possible acute coronary syndromes. N Engl J Med.
470
2012;366(15):1393-1403. doi:10.1056/NEJMoa1201163 12.
Hoffmann U, Truong QA, Schoenfeld DA, et al. Coronary CT angiography
RI PT
471 472
versus standard evaluation in acute chest pain. N Engl J Med.
473
2012;367(4):299-308. doi:10.1056/NEJMoa1201161 13.
Hamilton-Craig C, Fifoot A, Hansen M, et al. Diagnostic performance and cost
SC
474
of CT angiography versus stress ECG--a randomized prospective study of
476
suspected acute coronary syndrome chest pain in the emergency department
477
(CT-COMPARE). Int J Cardiol. 2014;177(3):867-873.
478
doi:10.1016/j.ijcard.2014.10.090
479
14.
M AN U
475
Linde JJ, Hove JD, Sorgaard M, et al. Long-Term Clinical Impact of Coronary CT Angiography in Patients With Recent Acute-Onset Chest Pain: The
481
Randomized Controlled CATCH Trial. JACC Cardiovasc Imaging.
482
2015;8(12):1404-1413. doi:10.1016/j.jcmg.2015.07.015 15.
Nielsen LH, Ortner N, Norgaard BL, Achenbach S, Leipsic J, Abdulla J. The diagnostic accuracy and outcomes after coronary computed tomography
AC C
484
angiography vs. conventional functional testing in patients with stable angina
485
pectoris: a systematic review and meta-analysis. Eur Heart J Cardiovasc
486
Imaging. 2014;15(9):961-971. doi:10.1093/ehjci/jeu027
487
488
EP
483
TE D
480
16.
Ghoshhajra BB, Takx RAP, Staziaki P V, et al. Clinical implementation of an
489
emergency department coronary computed tomographic angiography protocol
490
for triage of patients with suspected acute coronary syndrome. Eur Radiol.
Page 25 of 34
ACCEPTED MANUSCRIPT 2017;27(7):2784-2793. doi:10.1007/s00330-016-4562-5
491
492
17.
Backus BE, Six AJ, Kelder JC, et al. A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol.
494
2013;168(3):2153-2158. doi:10.1016/j.ijcard.2013.01.255
495
18.
RI PT
493
Than M, Flaws D, Sanders S, et al. Development and validation of the
Emergency Department Assessment of Chest pain Score and 2 h accelerated
497
diagnostic protocol. Emerg Med Australas. 2014;26(1):34-44.
498
doi:10.1111/1742-6723.12164 19.
Meyersohn NM, Szilveszter B, Staziaki P V, et al. Coronary CT angiography in
M AN U
499
SC
496
500
the emergency department utilizing second and third generation dual source
501
CT. J Cardiovasc Comput Tomogr. 2017;11(4):249-257.
502
doi:10.1016/j.jcct.2017.03.002 20.
Raff GL, Abidov A, Achenbach S, et al. SCCT guidelines for the interpretation
TE D
503
and reporting of coronary computed tomographic angiography. J Cardiovasc
505
Comput Tomogr. 2009;3(2):122-136. doi:10.1016/j.jcct.2009.01.001
506
21.
EP
504
Cury RC, Abbara S, Achenbach S, et al. CAD-RADS(TM) Coronary Artery Disease - Reporting and Data System. An expert consensus document of the
AC C
507
Society of Cardiovascular Computed Tomography (SCCT), the American
508
College of Radiology (ACR) and the North American Society for
509 510
Cardiovascular Imaging (. J Cardiovasc Comput Tomogr. 2016;10(4):269-281.
511
doi:10.1016/j.jcct.2016.04.005
512 513
22.
Seneviratne SK, Truong QA, Bamberg F, et al. Incremental diagnostic value of regional left ventricular function over coronary assessment by cardiac Page 26 of 34
ACCEPTED MANUSCRIPT 514
computed tomography for the detection of acute coronary syndrome in patients
515
with acute chest pain: from the ROMICAT trial. Circ Cardiovasc Imaging.
516
2010;3(4):375-383. doi:10.1161/CIRCIMAGING.109.892638 23.
Staziaki PV, Kim P, Vadvala H V, Ghoshhajra BB. Medical Registry Data
RI PT
517
Collection Efficiency: A Crossover Study Comparing Web-Based Electronic
519
Data Capture and a Standard Spreadsheet. J Med Internet Res.
520
2016;18(6):e141. doi:10.2196/jmir.5576
521
24.
SC
518
Truong QA, Schulman-Marcus J, Zakroysky P, et al. Coronary CT Angiography Versus Standard Emergency Department Evaluation for Acute
523
Chest Pain and Diabetic Patients: Is There Benefit With Early Coronary CT
524
Angiography? Results of the Randomized Comparative Effectiveness
525
ROMICAT II Trial. J Am Heart Assoc. 2016;5(3):e003137.
526
doi:10.1161/JAHA.115.003137
TE D
25.
Pursnani A, Chou ET, Zakroysky P, et al. Use of Coronary Artery Calcium Scanning Beyond Coronary Computed Tomographic Angiography in the
529
Emergency Department Evaluation for Acute Chest Pain: The ROMICAT II
530
Trial. Circ Cardiovasc Imaging. 2015;8(3):e002225-e002225.
531
533 534
angiography in a large urban health care system. AJR Am J Roentgenol.
535
2013;200(1):57-65. doi:10.2214/AJR.12.8808
532
536
EP
528
AC C
527
M AN U
522
doi:10.1161/CIRCIMAGING.114.002225
26.
Cury RC, Feuchtner GM, Batlle JC, et al. Triage of patients presenting with
chest pain to the emergency department: implementation of coronary CT
27.
Uretsky S, Rozanski A, Supariwala A, et al. Clinical outcomes following a
Page 27 of 34
ACCEPTED MANUSCRIPT 537
strategy of optimized medical management and selective “downstream”
538
procedures following coronary computed tomography angiography. Int J
539
Cardiol. 2013;165(3):468-473. doi:10.1016/j.ijcard.2011.08.852 28.
2012;367(4):375-376. doi:10.1056/NEJMe1206040
541
542
Redberg RF. Coronary CT angiography for acute chest pain. N Engl J Med.
29.
RI PT
540
Dedic A, Lubbers MM, Schaap J, et al. Coronary CT Angiography for
Suspected ACS in the Era of High-Sensitivity Troponins: Randomized
544
Multicenter Study. J Am Coll Cardiol. 2016;67(1):16-26.
545
doi:10.1016/j.jacc.2015.10.045 30.
M AN U
546
SC
543
Farkouh ME, Douglas PS. The Management of Acute Chest Pain: What Lies
547
Beyond the Emergency Department Doors? J Am Coll Cardiol. 2016;67(1):27-
548
28. doi:10.1016/j.jacc.2015.09.104 31.
Board Fam Med. 2012;25 Suppl 1:S12-7. doi:10.3122/jabfm.2012.02.110212
550
32.
Katz DA, Williams GC, Brown RL, et al. Emergency physicians’ fear of
EP
551
van Weel C, Schers H, Timmermans A. Health care in the Netherlands. J Am
TE D
549
malpractice in evaluating patients with possible acute cardiac ischemia. Ann
553
Emerg Med. 2005;46(6):525-533. doi:10.1016/j.annemergmed.2005.04.016
554 555
33.
AC C
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Badri M. Medical malpractice litigation: a fellow’s perspective. J Am Coll
Cardiol. 2014;64(4):418-419. doi:10.1016/j.jacc.2014.06.013
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10. Figure legends 10.1.
Figure 1. Typical flow of potential ACS patients from the ED to
coronary CTA ACS - Acute Coronary Syndrome; ED - Emergency Department; CTA - Computed
562
Tomographic Angiography; PA - Physician Assistant; ECG - Electrocardiogram;
563
STEMI - ST-segment Elevation Myocardial Infarction; NSTEMI - Non-ST segment
564
Elevation Myocardial Infarction
565
* An additional set of [Troponin] could be assessed
566
◊ Inpatient floor options are; monitored bed on internal medicine floor, cardiac acces-
567
/ 'step-down unit' (SDU) or coronary care unit (CCU)
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Typical flow
Atypical flow
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10.2.
Table 1. Subject Characteristics
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10.3.
Figure 2. Coronary CTA results and following diagnostic work-ups
CTA - Computed Tomography Angiography; SCRST - Secondary Cardiac Risk
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Stratifying Test; ICA - Invasive Coronary Angiography; SPECT - Single-Photon
575
Emission Computed Tomography; ETT - Exercise Tolerance Testing
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10.4.
Figure 3.
69 y/o male whom presented to the emergency department with 2 days of worsening
579
left and mid chest pain (and negative initial biomarkers and ECG). CTA showed
580
moderate left main stenosis (arrow) and mid left anterior descending artery stenoses
581
(arrowheads), as well as severe disease in small marginal branches and the distal
582
RCA (not shown). After confirmation by invasive coronary angiography (right image),
583
he underwent successful coronary artery bypass grafting.
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10.5.
Figure 4.
59 y/o woman with chief complaint of chest pain and dizziness: CTA demonstrates a
587
chronic total occlusion of the proximal RCA (panel 4A, arrowheads), with left-to right
588
and right-to-right collaterals (panel 4A, arrow). CT also depicted an inferior basal
589
aneurysm, seen here on systolic short axis and 2-chamber 8 mm thick mulitplanar
590
reformatted images (panels 4B & 4C, arrowheads) which were corroborated by
591
subsequent cardiac ultrasound performed the same day (panel 4D, arrowheads).
592
The patient was discharged on maximal medical therapy; after 3 months without
593
resolution of symptoms, she underwent ICA that showed unchanged chronic total
594
occlusion of the proximal RCA (panel 4E, arrowheads) and the left-to right and right-
595
to-right collaterals (panel 4F, arrow) and received successful percutaneous coronary
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intervention on the right coronary artery, with resolution of symptoms.
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598
Appendix. CAD-RADS reporting and data system for patients
presenting with stable chest pain21
599
The CAD-RADS classification should be applied on a per-patient basis for the
601
clinically most relevant (usually highest-grade) stenosis.
602
All vessels greater than 1.5 mm in diameter should be graded for stenosis severity.
603
CAD-RADS will not apply for smaller vessels (<1.5 mm in diameter).
604
MODIFIERS: If more than one modifier is present, the symbol “/” (slash) should
605
follow each modifier in the following order:
606
First: modifier N (non-diagnostic)
607
Second: modifier S (stent)
608
Third: modifier G (graft)
609
Fourth: modifier V (vulnerability)
610
a
CAD - coronary artery disease
611
b
CAD-RADS 1 - This category should also include the presence of plaque with
612
positive remodeling and no evidence of stenosis
613
c
Guideline-directed care per ACC Stable Ischemic Heart Disease Guidelines
614
d
ICA - invasive coronary angiography
615
(Reprinted, by permission from Elsevier, from Cury RC, Abbara S, Achenbach S, et
616
al. CAD-RADS(TM) Coronary Artery Disease - Reporting and Data System. An
617
expert consensus document of the Society of Cardiovascular Computed
618
Tomography (SCCT), the American College of Radiology (ACR) and the North
619
American Society for Cardiovascular Imaging. J Cardiovasc Comput Tomogr.
620
2016;10(4):269-281. doi:10.1016/j.jcct.2016.04.005)
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ACCEPTED MANUSCRIPT Further Cardiac Investigation
Degree of maximal coronary stenosis Interpretation
a
CAD-RADS 0
0% (No plaque or stenosis)
Documented absence of CAD
None
CAD-RADS 1
1-24% - Minimal stenosis or plaque b with no stenosis
Minimal non-obstructive CAD
None
Management - Reassurance. Consider non- atherosclerotic causes of chest pain - Consider non- atherosclerotic causes of chest pain - Consider preventive therapy and risk factor modification
25-49% Mild stenosis
Mild non-obstructive CAD
None
CAD-RADS 3
50-69% stenosis
Moderate stenosis
Consider functional assessment
CAD-RADS 4
A - 70-99% stenosis or
Severe stenosis
A: Consider ICA or functional assessment
B - Left main >50% or 3-vessel obstructive (≥70%) disease
d
B: ICA is recommended
100% (total occlusion)
Total coronary occlusion
Consider ICA and/or viability assessment
CAD-RADS N
Non-diagnostic study
Obstructive CAD cannot be excluded Additional or alternative evaluation may be needed
- Consider symptom-guided anti-ischemic and preventive pharmacotherapy as well as risk factor modification per guideline-directed carec - Other treatments (including options of revascularization) c should be considered per guideline-directed care
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CAD-RADS 5
- Consider non- atherosclerotic causes of chest pain - Consider preventive therapy and risk factor modification, particularly for patients with non- obstructive plaque in multiple segments - Consider symptom-guided anti-ischemic and preventive pharmacotherapy as well as risk factor modification per guideline-directed carec - Other treatments should be considered per guidelinec directed care - Consider symptom-guided anti-ischemic and preventive pharmacotherapy as well as risk factor modification per guideline-directed carec - Other treatments (including options of revascularization) should be considered per guideline-directed carec
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CAD-RADS 2
ACCEPTED MANUSCRIPT ±10.8 (3.8%) (18.2%) (36.2%) (27.3% (11.7%) (2.2%) (0.5%)
1061
(55.4%)
1293 202 73 348
(67.5%) (10.5%) (3.8%) (18.2%)
1598 199 119 29.6 224 518 740
(83.4%) (10.4%) (6.2%) ±6.3 (11.7%) (27.0%) (38.6%)
SC
52.9 73 348 694 524 225 43 9
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Age mean ≥ 18 - 34 years 35 - 44 years 45 - 54 years 55 - 64 years 65 - 74 years 75 - 84 years ≥ 85 years Gender Male Race Caucasian African-American Asian Other / Unknown Ethnicity Not hispanic/Latino Hispanic/Latino Unknown Body mass index (BMI) Diabetes Mellitis Dyslipidemia Hypertension
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N=1916
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Demographics