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CCTA in patients with positive troponin and low clinical suspicion for ACS: a useful diagnostic option to exclude obstructive CAD

  • James P. NugentEmail author
  • Jun Wang
  • Luck J. Louis
  • Tim W. O’Connell
  • Faisal Khosa
  • Graham C. Wong
  • Jacqueline W. L. Saw
  • Savvas Nicolaou
  • Patrick D. McLaughlin
Original Article

Abstract

Purpose

It is uncertain whether patients with elevated troponin and non-classical presentation of acute coronary syndrome (ACS) should receive coronary CT angiography (CCTA). A proportion of these patients will have no coronary artery disease (CAD) and would benefit from non-invasive investigations and expedited discharge. Objectives were to determine most common diagnoses and rate of ACS among patients with positive troponin and low clinical suspicion of ACS who received CCTA.

Methods

IRB approved retrospective analysis of 491 consecutive patients in a level I trauma center ED referred for CCTA between April 4, 2015 to April 2, 2017. Patients were included if there was an elevated troponin (TnI > 0.045 μg/L) and atypical chest pain within 24 h prior to imaging. One hundred one patients met inclusion criteria; 17 excluded due to technical factors or history. Scans performed on dual-source CT.

Results

Eighty-four patients (47 men, 37 women) with median TnI of 0.11 ± 0.21 μg/L underwent CCTA 8.20 ± 6.41 h after first elevated Tn. Mean age was 53.2 ± 14.6 years. CCTA demonstrated absence of CAD in 39 patients (46.4%; 20 M, 19 F). CAD < 25% stenosis was observed in 24 (28.6%; 9 M, 15 F). CAD with 25–50% stenosis was observed in seven (8.3%; six M, one F). CAD > 50% stenosis was observed in 11 (13.1%; 9 M, 2 F), and non-diagnostic in three (3.6%, 3 M, 0 F). Forty-six (56.8%) were discharged directly from ED with median stay 15.82 ± 6.41 h.

Conclusions

Use of CCTA in ED patients with elevated troponin and low clinical suspicion for ACS allowed obstructive CAD to be excluded in 83%.

Keywords

Coronary artery disease Acute coronary syndrome Troponin Coronary computed tomography angiography 

Notes

Acknowledgments

We sincerely thank Dr. Morris Pudek, the Regional Medical Leader for Clinical Chemistry at Vancouver Coastal Health for his help in obtaining the troponin assay protocol and explaining the biochemistry involved in troponin detection.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

References

  1. 1.
    Bakshi TK, Choo MK, Edwards CC, Scott AG, Hart HH, Armstrong GP (2002) Causes of elevated troponin I with a normal coronary angiogram. Intern Med J 32:520–525.  https://doi.org/10.1046/j.1445-5994.2002.00270.x CrossRefGoogle Scholar
  2. 2.
    Mahajan N, Mehta Y, Rose M, Shani J, Lichstein E (2006) Elevated troponin level is not synonymous with myocardial infarction. Int J Cardiol 111(3):442–449.  https://doi.org/10.1016/j.ijcard.2005.08.029 CrossRefGoogle Scholar
  3. 3.
    Saenger AK, Jaffe AS (2008) Requiem for a heavyweight: the demise of creatine kinase-MB. Circulation 118(21):2200–2206.  https://doi.org/10.1161/CIRCULATIONAHA.108.773218 CrossRefGoogle Scholar
  4. 4.
    Agewall S, Giannitsis E, Jernberg T, Katus H (2011) Troponin elevation in coronary vs. non-coronary disease. Eur Heart J 32(4):404–411.  https://doi.org/10.1093/eurheartj/ehq456 CrossRefGoogle Scholar
  5. 5.
    Amsterdam EA, Wenger NK, Brindis RG, Casey DE Jr, Ganiats TG, Holmes DR Jr, Jaffe AS, Jneid H, Kelly RF, Kontos MC, Levine GN, Liebson PR, Mukherjee D, Peterson ED, Sabatine MS, Smalling RW, Zieman SJ, Members AATF (2014) 2014 AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association task Force on practice guidelines. Circulation 130(25):e344–e426.  https://doi.org/10.1161/CIR.0000000000000134 Google Scholar
  6. 6.
    Tavakol M, Ashraf S, Brener SJ (2012) Risks and complications of coronary angiography: a comprehensive review. Global J Health Sci 4(1):65–93.  https://doi.org/10.5539/gjhs.v4n1p65 Google Scholar
  7. 7.
    Haberl R, Tittus J, Bohme E, Czernik A, Richartz BM, Buck J, Steinbigler P (2005) Multislice spiral computed tomographic angiography of coronary arteries in patients with suspected coronary artery disease: an effective filter before catheter angiography? Am Heart J 149(6):1112–1119.  https://doi.org/10.1016/j.ahj.2005.02.048 CrossRefGoogle Scholar
  8. 8.
    Raff GL, Chinnaiyan KM, Cury RC, Garcia MT, Hecht HS, Hollander JE, O’Neil B, Taylor AJ, Hoffmann U, Society of Cardiovascular Computed Tomography Guidelines C (2014) SCCT guidelines on the use of coronary computed tomographic angiography for patients presenting with acute chest pain to the emergency department: a report of the Society of Cardiovascular Computed Tomography Guidelines Committee. J Cardiovasc Comput Tomogr 8(4):254–271.  https://doi.org/10.1016/j.jcct.2014.06.002 CrossRefGoogle Scholar
  9. 9.
    Shrimpton PC, Hillier MC, Lewis MA, Dunn M (2005) Doses from computed tomography (CT) examinations in the UK—2003 review. UK National Radiological Protection Board (NRPB-W67)Google Scholar
  10. 10.
    Januzzi JL Jr, Bamberg F, Lee H, Truong QA, Nichols JH, Karakas M, Mohammed AA, Schlett CL, Nagurney JT, Hoffmann U, Koenig W (2010) High-sensitivity troponin T concentrations in acute chest pain patients evaluated with cardiac computed tomography. Circulation 121(10):1227–1234.  https://doi.org/10.1161/CIRCULATIONAHA.109.893826 CrossRefGoogle Scholar
  11. 11.
    Januzzi JL, Sharma U, Zakroysky P, Truong QA, Woodard PK, Pope JH, Hauser T, Mayrhofer T, Nagurney JT, Schoenfeld D, Peacock WF, Fleg JL, Wiviott S, Pang PS, Udelson J, Hoffmann U (2015) Sensitive troponin assays in patients with suspected acute coronary syndrome: results from the multicenter rule out myocardial infarction using computer assisted tomography II trial. Am Heart J 169(4):572–578 e571.  https://doi.org/10.1016/j.ahj.2014.12.023 CrossRefGoogle Scholar
  12. 12.
    Yeh RW, Sidney S, Chandra M, Sorel M, Selby JV, Alan SG (2010) Population trends in the incidence and outcomes of acute myocardial infarction. N Engl J Med 362(23):2155–2165.  https://doi.org/10.1056/NEJMoa0908610 CrossRefGoogle Scholar
  13. 13.
    Hollander JE, Chang AM, Shofer FS, McCusker CM, Baxt WG, Litt HI (2009) Coronary computed tomographic angiography for rapid discharge of low-risk patients with potential acute coronary syndromes. Ann Emerg Med 53(3):295–304.  https://doi.org/10.1016/j.annemergmed.2008.09.025 CrossRefGoogle Scholar
  14. 14.
    deFilippi CR, Tocchi M, Parmar RJ, Rosanio S, Abreo G, Potter MA, Runge MS, Uretsky BF (2000) Cardiac troponin T in chest pain unit patients without ischemic electrocardiographic changes: angiographic correlates and long-term clinical outcomes. J Am Coll Cardiol 35(7):1827–1834.  https://doi.org/10.1016/s0735-1097(00)00628-8 CrossRefGoogle Scholar
  15. 15.
    Nikolaou K, Knez A, Rist C, Wintersperger BJ, Leber A, Johnson T, Reiser MF, Becker CR (2006) Accuracy of 64-MDCT in the diagnosis of ischemic heart disease. AJR Am J Roentgenol 187(1):111–117.  https://doi.org/10.2214/AJR.05.1697 CrossRefGoogle Scholar
  16. 16.
    Ropers D, Rixe J, Anders K, Kuttner A, Baum U, Bautz W, Daniel WG, Achenbach S (2006) Usefulness of multidetector row spiral computed tomography with 64- x 0.6-mm collimation and 330-ms rotation for the noninvasive detection of significant coronary artery stenoses. Am J Cardiol 97(3):343–348.  https://doi.org/10.1016/j.amjcard.2005.08.050 CrossRefGoogle Scholar
  17. 17.
    Schuijf JD, Pundziute G, Jukema JW, Lamb HJ, van der Hoeven BL, de Roos A, van der Wall EE, Bax JJ (2006) Diagnostic accuracy of 64-slice multislice computed tomography in the noninvasive evaluation of significant coronary artery disease. Am J Cardiol 98(2):145–148.  https://doi.org/10.1016/j.amjcard.2006.01.092 CrossRefGoogle Scholar
  18. 18.
    Goldstein JA, Gallagher MJ, O’Neill WW, Ross MA, O’Neil BJ, Raff GL (2007) A randomized controlled trial of multi-slice coronary computed tomography for evaluation of acute chest pain. J Am Coll Cardiol 49(8):863–871.  https://doi.org/10.1016/j.jacc.2006.08.064 CrossRefGoogle Scholar
  19. 19.
    Hoffmann U, Bamberg F, Chae CU, Nichols JH, Rogers IS, Seneviratne SK, Truong QA, Cury RC, Abbara S, Shapiro MD, Moloo J, Butler J, Ferencik M, Lee H, Jang IK, Parry BA, Brown DF, Udelson JE, Achenbach S, Brady TJ, Nagurney JT (2009) Coronary computed tomography angiography for early triage of patients with acute chest pain: the ROMICAT (rule out myocardial infarction using computer assisted tomography) trial. J Am Coll Cardiol 53(18):1642–1650.  https://doi.org/10.1016/j.jacc.2009.01.052 CrossRefGoogle Scholar
  20. 20.
    Goldstein JA, Chinnaiyan KM, Abidov A, Achenbach S, Berman DS, Hayes SW, Hoffmann U, Lesser JR, Mikati IA, O’Neil BJ, Shaw LJ, Shen MY, Valeti US, Raff GL, Investigators C-S (2011) The CT-STAT (coronary computed tomographic angiography for systematic triage of acute chest pain patients to treatment) trial. J Am Coll Cardiol 58(14):1414–1422.  https://doi.org/10.1016/j.jacc.2011.03.068 CrossRefGoogle Scholar
  21. 21.
    Litt HI, Gatsonis C, Snyder B, Singh H, Miller CD, Entrikin DW, Leaming JM, Gavin LJ, Pacella CB, Hollander JE (2012) CT angiography for safe discharge of patients with possible acute coronary syndromes. N Engl J Med 366:1393–1403.  https://doi.org/10.1056/NEJMoa1201163 CrossRefGoogle Scholar
  22. 22.
    Hoffmann U, Truong QA, Schoenfeld DA, Chou ET, Woodard PK, Nagurney JT, Pope JH, Hauser TH, White CS, Weiner SG, Kalanjian S, Mullins ME, Mikati I, Peacock WF, Zakroysky P, Hayden D, Goehler A, Lee H, Gazelle GS, Wiviott SD, Fleg JL, Udelson JE, Investigators R-I (2012) Coronary CT angiography versus standard evaluation in acute chest pain. N Engl J Med 367(4):299–308.  https://doi.org/10.1056/NEJMoa1201161 CrossRefGoogle Scholar
  23. 23.
    Altintas S, Cardinaels EP, Versteylen MO, Joosen IA, Seifert M, Wildberger JE, Crijns HJ, Nelemans PJ, Van Dieijen-Visser MP, Mingels AM, Das M, Kietselaer BL (2016) Unstable coronary plaque characteristics are associated with high-sensitivity cardiac troponin T and N-terminal pro-brain natriuretic peptide. J Cardiovasc Comput Tomogr 10(1):82–88.  https://doi.org/10.1016/j.jcct.2015.10.001 CrossRefGoogle Scholar

Copyright information

© American Society of Emergency Radiology 2019

Authors and Affiliations

  • James P. Nugent
    • 1
    Email author return OK on get
  • Jun Wang
    • 1
  • Luck J. Louis
    • 1
  • Tim W. O’Connell
    • 1
  • Faisal Khosa
    • 1
  • Graham C. Wong
    • 2
  • Jacqueline W. L. Saw
    • 2
  • Savvas Nicolaou
    • 1
  • Patrick D. McLaughlin
    • 1
  1. 1.Radiology DepartmentVancouver General HospitalVancouverCanada
  2. 2.Cardiology DepartmentVancouver General HospitalVancouverCanada

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