| 1. Foy AJ, Liu G, Davidson WR Jr, Sciamanna C, Leslie DL. Comparative effectiveness of diagnostic testing strategies in emergency department patients with chest pain: an analysis of downstream testing, interventions, and outcomes. JAMA Internal Medicine. 175(3):428-36, 2015 Mar.JAMA Intern Med. 175(3):428-36, 2015 Mar. |
Review/Other-Dx |
421,774 patients |
To compare chest pain evaluation pathways based on their association with downstream testing, interventions, and outcomes for patients in EDs. |
In 2011, there were 693 212 ED visits with a primary or secondary diagnosis of chest pain, accounting for 9.2% of all ED encounters. After application of the inclusion and exclusion criteria, 421 774 patients were included in the final analysis; 293 788 individuals did not receive an initial noninvasive test and 127 986 did, representing 1.7% of all ED encounters. Overall, the percentage of patients hospitalized with an MI was very low during both 7 and 190 days of follow-up (0.11% and 0.33%, respectively). Patients who did not undergo initial noninvasive testing were no more likely to experience an MI than were those who did receive testing. Compared with no testing, exercise electrocardiography, myocardial perfusion scintigraphy, and coronary computed tomography angiography were associated with significantly higher odds of cardiac catheterization and revascularization procedures without a concomitant improvement in the odds of experiencing an MI. |
4 |
| 2. Dai S, Huang B, Zou Y, et al. The HEART score is useful to predict cardiovascular risks and reduces unnecessary cardiac imaging in low-risk patients with acute chest pain. Medicine (Baltimore). 97(22):e10844, 2018 Jun. |
Observational-Dx |
244 patients |
To investigate whether the HEART score can be used to evaluate cardiovascular risks and reduce unnecessary cardiac imaging in China. |
A total of 244 patients were enrolled and 2 was loss of follow-up. The mean age was 50.4 years old and male patients accounted for 64.5%. Substernal pain and featured as pressure of the pain accounted for 34.3% and 39.3%, respectively. After 30 days' follow-up, no patient in the low-risk HEART score group and 2 patients (1.5%) in the high risk HEART score group had cardiovascular events. The sensitivity of HEART score to predict cardiovascular events was 100% and the specificity was 46.7%. The potential unnecessary cardiac testing was 46.3%. Cox proportional hazards regression analysis showed that per one category increase of the HEART score was associated with nearly 1.3-fold risk of cardiovascular events. |
3 |
| 3. Kolff AQ, Bom MJ, Knol RJ, van de Zant FM, van der Zee PM, Cornel JH. Discriminative Power of the HEART Score for Obstructive Coronary Artery Disease in Acute Chest Pain Patients Referred for CCTA. Crit. pathw. cardiol.. 15(1):6-10, 2016 Mar. |
Observational-Dx |
710 patients |
To investigate the ability of the HEART score to predict the presence of obstructive coronary artery disease (CAD) determined by coronary computed tomography angiography (CCTA) and its ability to predict the occurrence of major adverse cardiac events (MACE) in patients referred for CCTA after emergency department (ED) presentation. |
During median follow-up of 826 days (interquartile range: 563-1056), MACE occurred in 46 (6.5%) patients; 3 (0.4%) myocardial infarction, 8 (1.1%) death, and 36 (5.1%) revascularizations. A low HEART score was a significant predictor for MACE-free survival (P = 0.010). CCTA revealed obstructive CAD in 11.7% of patients, with no significant difference between patients with a low and intermediate/high HEART score, respectively 10.7% and 13.2% (P = 0.29). The ability of the HEART score to identify obstructive CAD was poor with an AUC of the receiver operating characteristics curve of 0.53. |
4 |
| 4. Mahler SA, Riley RF, Hiestand BC, et al. The HEART Pathway randomized trial: identifying emergency department patients with acute chest pain for early discharge. Circ Cardiovasc Qual Outcomes. 8(2):195-203, 2015 Mar. |
Observational-Dx |
282 patients |
To determine whether the HEART Patheway can meaningfully reduce objective cardiac testing, increase early discharges, and reduce index hospital length of stay (LOS) compared with usual care while maintaining high sensitivity and NPV (>99%) for MACE |
Adult emergency department patients with symptoms related to acute coronary syndrome without ST-elevation on ECG (n=282) were randomized to the HEART Pathway or usual care. In the HEART Pathway arm, emergency department providers used the HEART score, a validated decision aid, and troponin measures at 0 and 3 hours to identify patients for early discharge. Usual care was based on American College of Cardiology/American Heart Association guidelines. The primary outcome, objective cardiac testing (stress testing or angiography), and secondary outcomes, index length of stay, early discharge, and major adverse cardiac events (death, myocardial infarction, or coronary revascularization), were assessed at 30 days by phone interview and record review. Participants had a mean age of 53 years, 16% had previous myocardial infarction, and 6% (95% confidence interval, 3.6%–9.5%) had major adverse cardiac events within 30 days of randomization. Compared with usual care, use of the HEART Pathway decreased objective cardiac testing at 30 days by 12.1% (68.8% versus 56.7%; P=0.048) and length of stay by 12 hours (9.9 versus 21.9 hours; P=0.013) and increased early discharges by 21.3% (39.7% versus 18.4%; P<0.001). No patients identified for early discharge had major adverse cardiac events within 30 days. |
2 |
| 5. Stopyra JP, Miller CD, Hiestand BC, et al. Chest Pain Risk Stratification: A Comparison of the 2-Hour Accelerated Diagnostic Protocol (ADAPT) and the HEART Pathway. Crit. pathw. cardiol.. 15(2):46-9, 2016 06. |
Observational-Dx |
141 Patients |
To compare the sensitivity and early discharge rates of the ADAPT and HEART Pathway decision aids in a cohort of ED patients with acute chest pain. |
MACE occurred in 8 of 141 (5.7%); there were no deaths, 7 patients had myocardial infarction, and 1 patient had coronary revascularization without myocardial infarction. ADAPT and the HEART pathway identified all patients with MACE as high risk; sensitivity for MACE of 100% [95% confidence interval (CI): 63-100%]. ADAPT identified 34 of 141 patients (24%; 95% CI: 17-32%) as low-risk, whereas the Heart pathway identified 66 of 141 patients (47%, 95% CI: 38-55%) as low risk (P < 0.001). |
3 |
| 6. Dedic A, Lubbers MM, Schaap J, et al. Coronary CT Angiography for Suspected ACS in the Era of High-Sensitivity Troponins: Randomized Multicenter Study. Journal of the American College of Cardiology. 67(1):16-26, 2016 Jan 05. |
Observational-Dx |
500 Patients |
To assess whether a diagnostic strategy supplemented by early CCTA improves clinical effectiveness compared with contemporary SOC. |
The study population consisted of 500 patients, of whom 236 (47%) were women (mean age 54 ± 10 years). There was no difference in the primary endpoint (22 [9%] patients underwent coronary revascularization within 30 days in the CCTA group and 17 [7%] in the SOC group [p = 0.40]). Discharge from the ED was not more frequent after CCTA (65% vs. 59%, p = 0.16), and length of stay was similar (6.3 h in both groups; p = 0.80). The CCTA group had lower direct medical costs (€337 vs. €511, p < 0.01) and less outpatient testing after the index ED visit (10 [4%] vs. 26 [10%], p < 0.01). There was no difference in incidence of undetected ACS. |
3 |
| 7. Ferencik M, Hoffmann U, Bamberg F, Januzzi JL. Highly sensitive troponin and coronary computed tomography angiography in the evaluation of suspected acute coronary syndrome in the emergency department. [Review]. European Heart Journal. 37(30):2397-405, 2016 08 07. |
Review/Other-Dx |
N/A |
To provide an overview of the evidence for the role of highly sensitive troponin (hsTn) in the rapid and efficient evaluation of suspected ACS. |
No results stated in abstract. |
4 |
| 8. Ferencik M, Mayrhofer T, Lu MT, et al. High-Sensitivity Cardiac Troponin I as a Gatekeeper for Coronary Computed Tomography Angiography and Stress Testing in Patients with Acute Chest Pain. Clin Chem. 63(11):1724-1733, 2017 Nov. |
Review/Other-Dx |
N/A |
To determine whether a combination of high-sensitivity cardiac troponin I (hs-cTnI) and cardiovascular risk factors might improve selection of patients for cardiac testing. |
A combination of baseline hs-cTnI (<4 ng/L) and cardiovascular risk factors (<2) ruled out ACS with a negative predictive value of 100% in ROMICAT I. We validated this criterion in ROMICAT II, identifying 29% patients as not needing cardiac testing. An additional 5% of patients were identified by adding no change or a decrease between baseline and 2 h hs-cTnI as a criterion. Assuming those patients would be discharged from the ED without cardiac testing, implementation of hs-cTnI would increase ED discharge rate (24.3% to 50.2%, P < 0.001) and decrease the length of hospital stay (21.4 to 8.2 h, P < 0.001), radiation dose (10.2 to 7.7 mSv, P < 0.001), and costs of care (4066 to 3342 US$, P < 0.001). |
4 |
| 9. Januzzi JL, Sharma U, Zakroysky P, et al. Sensitive troponin assays in patients with suspected acute coronary syndrome: Results from the multicenter rule out myocardial infarction using computer assisted tomography II trial. American Heart Journal. 169(4):572-8.e1, 2015 Apr. |
Observational-Dx |
322 patients |
To compare the performance of a commercially available sensitive troponin I (sTnI) and pre-commercial highly sensitive (hs) TnI method to conventional (c)Tn assays. |
Of 322 subjects, all had a cTn that was normal at screening; 28 (8.7%) were subsequently diagnosed with ACS. Of these, 21 had unstable angina pectoris (UAP); of the acute MIs, none had ST segment elevation. The mean age of the sample was 53 years, and 58% were male. Table 1 details the baseline demographics and clinical characteristics of the subjects with ACS versus those without. The time from presentation to study enrollment was (mean ± standard deviation) 3.2 ± 1.1 hours overall; there was no difference in time from presentation to enrollment between those with and without ACS (3.1 ± 1.3 versus 3.2 ± 1.1 hours; P =0.74). No patients had myocarditis, heart failure, or pulmonary embolism. |
2 |
| 10. Liu T, Wang G, Li P, Dai X. Risk classification of highly sensitive troponin I predict presence of vulnerable plaque assessed by dual source coronary computed tomography angiography. The International Journal of Cardiovascular Imaging. 33(11):1831-1839, 2017 Nov. |
Observational-Dx |
220 patients |
To study the association of highly sensitive troponin (hsTn) I with vulnerable plaque features as detected by coronary dual source computed tomography angiography (DSCTA) and determine whether hsTn I at the time of presentation combined with early DSCTA could improve classification of patients as high-risk or low risk for ACS. |
ACS during the index hospitalization occurred in 36 (16.3%) patients (myocardial infarction n?=?8, unstable angina pectoris n?=?28). HsTn I was below the limit of detection, intermediate, and above 99th percentile in 39 (17.7%), 139 (86.9%), and 42 (19.1%) patients, respectively. Across the categories of low risk, intermediate and high risk of hsTn I, there was increase in prevalence of =50% stenosis (0, 11.5, and 61.9% of patients; p?<?0.001), any plaque (35.9, 51.1, and 85.7% of patients; p?<?0.001) and high-risk plaque (0, 36.0, and 85.7% of patients; p?<?0.001). None of the patients in low risk HsTn I group had ACS. ACS occurred in 10.1% of the intermediate hsTn I group and in 52.3% of the patients with high risk hsTnI group. Severity of stenosis and presence of vunerable plaque as detected by DSCTA are associated with increasing levels of hsTn I. DSCTA at the time of presentation with the assessment for both stenosis and high-risk plaque improved the diagnostic accuracy for ACS in the intermediate hsTn I group patients. |
4 |
| 11. Smulders MW, Kietselaer BL, Schalla S, et al. Acute chest pain in the high-sensitivity cardiac troponin era: A changing role for noninvasive imaging?. [Review]. Am Heart J. 177:102-11, 2016 07. |
Review/Other-Dx |
N/A |
To describe the anticipation of a potential changing role of noninvasive imaging from ruling out myocardial disease when troponin values are normal toward characterizing myocardial disease when hs-cTn values are (mildly) abnormal. |
No results stated in the abstract. |
4 |
| 12. Hoffmann U, Truong QA, Schoenfeld DA, et al. Coronary CT angiography versus standard evaluation in acute chest pain. N Engl J Med. 367(4):299-308, 2012 Jul 26. |
Experimental-Dx |
1,000 patients randomized to CCTA (n=501) and standard evaluation (n=499) |
To compare the effectiveness of a CCTA-based evaluation strategy with that of standard evaluation in the ED for patients with symptoms suggestive of an ACS and to evaluate the downstream testing, cost, and radiation exposure associated with CCTA. |
The rate of ACSs among 1,000 patients with a mean (± standard deviation) age of 54 ± 8 years (47% women) was 8%. After early CCTA, as compared with standard evaluation, the mean length of stay in the hospital was reduced by 7.6 hours (P<0.001) and more patients were discharged directly from the ED (47% vs 12%, P<0.001). There were no undetected ACSs and no significant differences in major adverse cardiovascular events at 28 days. After CCTA, there was more downstream testing and higher radiation exposure. The cumulative mean cost of care was similar in the CCTA group and the standard evaluation group ($4,289 and $4,060, respectively; P=0.65). |
1 |
| 13. Litt HI, Gatsonis C, Snyder B, et al. CT angiography for safe discharge of patients with possible acute coronary syndromes. N Engl J Med. 2012; 366(15):1393-1403. |
Experimental-Dx |
1,370 patients: 908 in the CCTA group and 462 in the group receiving traditional care |
To determine the safety and efficiency of a CCTA-based strategy. The study compared a CCTA-based strategy with traditional “rule out” approaches for low-to-intermediate- risk patients presenting to the ED with chest pain and possible ACS. |
Of 640 patients with a negative CCTA examination, none died or had a MI within 30 days (0%; 95% CI, 0 to 0.57). As compared with patients receiving traditional care, patients in the CCTA group had a higher rate of discharge from the ED (49.6% vs 22.7%; difference, 26.8 percentage points; 95% CI, 21.4 to 32.2), a shorter length of stay (median, 18.0 hours vs 24.8 hours; P<0.001), and a higher rate of detection of coronary disease (9.0% vs 3.5%; difference, 5.6 percentage points; 95% CI, 0 to 11.2). There was one serious adverse event in each group. |
1 |
| 14. Raff GL, Hoffmann U, Udelson JE. Trials of Imaging Use in the Emergency Department for Acute Chest Pain. [Review]. Jacc: Cardiovascular Imaging. 10(3):338-349, 2017 Mar. |
Review/Other-Dx |
N/A |
To review multiple randomized trials that suggest that adjunctive noninvasive imaging is safe and effective in expediting care and reducing hospital admissions for low- to intermediate-risk patients with acute chest pain (ACP). |
No results stated in abstract. |
4 |
| 15. Breuckmann F, Hochadel M, Voigtlander T, et al. The Use of Echocardiography in Certified Chest Pain Units: Results from the German Chest Pain Unit Registry. Cardiology. 134(2):75-83, 2016. |
Observational-Dx |
23,997 patients |
To analyze the current usage of transthoracic echocardiography (TTE) as a rapid, noninvasive tool in the early stratification of acute chest pain in certified German chest pain units (CPUs). |
TTE evaluation was available in CPUs in 70.1% of cases. It was associated with lower rates of invasive management in unstable angina pectoris (UAP) and with higher rates in patients with initially suspected non-cardiac origin of symptoms and/or reduced systolic function (p < 0.05). Non-ST-segment elevation acute coronary syndrome (NSTE-ACS) was an independent determinant favoring TTE evaluation [NSTE-myocardial infarction: odds ratio (OR) 1.62; UAP: OR 1.34; p < 0.001 for both]. Clinical signs of heart failure (OR 1.31; p < 0.001), referral by emergency medical service (OR 1.18; p < 0.001) and kidney failure (OR 1.16; p < 0.05) were independently associated with higher TTE rates. TTE did not delay door-to-balloon times. |
4 |
| 16. Hollander JE, Than M, Mueller C. State-of-the-Art Evaluation of Emergency Department Patients Presenting With Potential Acute Coronary Syndromes. [Review]. Circulation. 134(7):547-64, 2016 Aug 16. |
Review/Other-Dx |
N/A |
To discuss state-of-the art evaluation methods for patients presenting with potential acute coronary syndromes. |
No results stated in the abstract. |
4 |
| 17. American College of Radiology. ACR Appropriateness Criteria®: Acute Chest Pain — Suspected Aortic Dissection. Available at: https://acsearch.acr.org/docs/69402/Narrative/ |
Review/Other-Dx |
N/A |
Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for a specific clinical condition. |
No abstract available. |
4 |
| 18. American College of Radiology. ACR Appropriateness Criteria®: Suspected Pulmonary Embolism. Available at: https://acsearch.acr.org/docs/69404/Narrative/. |
Review/Other-Dx |
N/A |
Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for a specific clinical condition. |
No abstract available. |
4 |
| 19. Scheirey CD, Fowler KJ, Therrien JA, et al. ACR Appropriateness Criteria® Acute Nonlocalized Abdominal Pain. J Am Coll Radiol 2018;15:S217-S31. |
Review/Other-Dx |
N/A |
Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for acute nonlocalized abdominal pain. |
No results stated in abstract. |
4 |
| 20. Yoo SM, Chun EJ, Lee HY, Min D, White CS. Computed Tomography Diagnosis of Nonspecific Acute Chest Pain in the Emergency Department: From Typical Acute Coronary Syndrome to Various Unusual Mimics. [Review]. J Thorac Imaging. 32(1):26-35, 2017 Jan. |
Review/Other-Dx |
N/A |
To present an overview of how to choose an appropriate CT protocol in patients with nonspecific acute chest pain and to provide specific CT findings of ACS and various mimics of ACS. |
No results stated in abstract. |
4 |
| 21. American College of Radiology. ACR–NASCI–SIR–SPR Practice Parameter for the Performance and Interpretation of Body Computed Tomography Angiography (CTA). Available at: https://www.acr.org/-/media/ACR/Files/Practice-Parameters/body-cta.pdf. |
Review/Other-Dx |
N/A |
Guidance document to promote the safe and effective use of diagnostic and therapeutic radiology by describing specific training, skills and techniques. |
No abstract available. |
4 |
| 22. Lancellotti P, Price S, Edvardsen T, et al. The use of echocardiography in acute cardiovascular care: recommendations of the European Association of Cardiovascular Imaging and the Acute Cardiovascular Care Association. European heart journal cardiovascular Imaging. 16(2):119-46, 2015 Feb. |
Review/Other-Dx |
N/A |
To describe the practical applications of echocardiography in patients with acute cardiovascular conditions, in particular with acute chest pain, acute hear failure, suspected cardiac tamponade, complications of MI, acute valvular heart disease including endocarditis, acute disease of the ascending aorta and post-intervention complications. |
No results stated in the abstract. |
4 |
| 23. Merchan Ortega G, Bonaque Gonzalez JC, Sanchez Espino AD, et al. Long-term prognostic value of peak exercise echocardiogram in patients hospitalized with acute chest pain. Echocardiography. 34(6):869-875, 2017 Jun. |
Observational-Dx |
250 patients |
To evaluate the prognostic value of EEcho in patients hospitalized for acute chest pain (CP) and its additional prognostic information regarding exercise electrocardiogram test (EECG). |
EEcho was positive in 16%. Patients with positive EEcho had a higher incidence of hypertension and higher TIMI risk score, showing significant CAD in 66%. We observed contradictory results (EECG-EEcho) in 20%. Patients with positive EEcho and negative EECG had significant CAD in the 66%, and patients undergoing coronary angiography with negative EEcho and positive EECG did not show significant coronary artery disease. Only positive EEcho (P<.001, HR 0.169; 95% CI, 0.088-0.250) and atrial fibrillation (P<.025, HR 0.125; 95% CI, 0.016-0.233) were independently associated with MACE during follow-up. In patients with negative EEcho, the presence of MACE was 2%. |
3 |
| 24. Levsky JM, Haramati LB, Spevack DM, et al. Coronary Computed Tomography Angiography Versus Stress Echocardiography in Acute Chest Pain: A Randomized Controlled Trial. Jacc: Cardiovascular Imaging. 11(9):1288-1297, 2018 09. |
Observational-Dx |
400 patients |
To compare early emergency department (ED) use of coronary computed tomography angiography (CTA) and stress echocardiography (SE) head-to-head. |
Mean patient age was 55 years, with 43% women and predominantly ethnic minorities (46% Hispanics, 32% African Americans). Thirty-nine coronary CTA patients (19%) and 22 SE patients (11%) were hospitalized at presentation (difference 8%; 95% confidence interval: 1% to 15%; p = 0.026). Median ED length of stay for discharged patients was 5.4 h (interquartile range [IQR]: 4.2 to 6.4 h) for coronary CTA and 4.7 h (IQR: 3.5 to 6.0 h) for SE (p < 0.001). Median hospital length of stay was 58 h (IQR: 50 to 102 h) for coronary CTA and 34 h (IQR: 31 to 54 h) for SE (p = 0.002). There were 11 and 7 major adverse cardiovascular events for coronary CTA and SE, respectively (p = 0.47), over a median 24 months of follow-up. Median/mean complete initial work-up radiation exposure was 6.5/7.7 mSv for coronary CTA and 0/0.96 mSv for SE (p < 0.001). |
3 |
| 25. Tragardh E, Tan SS, Bucerius J, et al. Systematic review of cost-effectiveness of myocardial perfusion scintigraphy in patients with ischaemic heart disease: A report from the cardiovascular committee of the European Association of Nuclear Medicine. Endorsed by the European Association of Cardiovascular Imaging. [Review]. European heart journal cardiovascular Imaging. 18(8):825-832, 2017 May 01. |
Review/Other-Dx |
57 Reports |
To review the published information on costs and cost-effectiveness of myocardial perfusion scintigraphy (MPS) over the past 25 years and compare them with other imaging and non-imaging techniques. |
No results stated in abstract. |
4 |
| 26. Kirsch J, Brown RKJ, Henry TS, et al. ACR Appropriateness Criteria R Acute Chest Pain-Suspected Pulmonary Embolism. J. Am. Coll. Radiol.. 14(5S):S2-S12, 2017 May. |
Review/Other-Dx |
N/A |
Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for acute chest pain-suspected pulmonary embolism. |
No results stated in abstract. |
4 |
| 27. Durand E, Bauer F, Mansencal N, et al. Head-to-head comparison of the diagnostic performance of coronary computed tomography angiography and dobutamine-stress echocardiography in the evaluation of acute chest pain with normal ECG findings and negative troponin tests: A prospective multicenter study. Int J Cardiol. 241:463-469, 2017 Aug 15. |
Observational-Dx |
217 Patients |
To perform a head-to-head comparison of coronary CT angiography (CCTA) and dobutamine-stress echocardiography (DSE) in patients presenting recent chest pain when troponin and ECG are negative. |
ICA was performed in 75 (34.6%) patients. Coronary artery stenosis was identified in 37 (17%) patients. For CCTA, the sensitivity was 96.9% (95% CI 83.4-99.9), specificity 48.3% (29.4-67.5), positive likelihood ratio 2.06 (95% CI 1.36-3.11), and negative likelihood ratio 0.07 (95% CI 0.01-0.52). The sensitivity of DSE was 51.6% (95% CI 33.1-69.9), specificity 46.7% (28.3-65.7), positive likelihood ratio 1.03 (95% CI 0.62-1.72), and negative likelihood ratio 1.10 (95% CI 0.63-1.93). The CCTA: DSE ratio of true-positive and false-positive rates was 1.70 (95% CI 1.65-1.75) and 1.00 (95% CI 0.91-1.09), respectively, when non-contributive CCTA and DSE were both considered positive. Only one missed acute coronary syndrome was observed at six months. |
1 |
| 28. Levsky JM, Spevack DM, Travin MI, et al. Coronary Computed Tomography Angiography Versus Radionuclide Myocardial Perfusion Imaging in Patients With Chest Pain Admitted to Telemetry: A Randomized Trial. Ann Intern Med. 163(3):174-83, 2015 Aug 04. |
Observational-Dx |
400 patients |
To compare CCTA with conventional noninvasive testing. |
Thirty (15%) patients who had CCTA and 32 (16%) who had MPI underwent cardiac catheterization within 1 year. Fifteen (7.5%) and 20 (10%) of these patients, respectively, did not undergo revascularization (difference, -2.5 percentage points [95% CI, -8.6 to 3.5 percentage points]; hazard ratio, 0.77 [CI, 0.40 to 1.49]; P = 0.44). Median length of stay was 28.9 hours for the CCTA group and 30.4 hours for the MPI group (P = 0.057). Median follow-up was 40.4 months. For the CCTA and MPI groups, the incidence of death (0.5% versus 3%; P = 0.12), nonfatal cardiovascular events (4.5% versus 4.5%), rehospitalization (43% versus 49%), emergency department visit (63% versus 58%), and outpatient cardiology visit (23% versus 21%) did not differ. Long-term, all-cause radiation exposure was lower for the CCTA group (24 versus 29 mSv; P < 0.001). More patients in the CCTA group graded their experience favorably (P = 0.001) and would undergo the examination again (P = 0.003). |
2 |
| 29. Nabi F, Kassi M, Muhyieddeen K, et al. Optimizing Evaluation of Patients with Low-to-Intermediate-Risk Acute Chest Pain: A Randomized Study Comparing Stress Myocardial Perfusion Tomography Incorporating Stress-Only Imaging Versus Cardiac CT. J Nucl Med. 57(3):378-84, 2016 Mar. |
Observational-Dx |
598 patients |
To determine whether stress myocardial perfusion (SPECT) optimized with stress-only (SO) imaging is comparable to cardiac CT angiography for evaluating patients with acute chest pain (ACP). |
Of 2,994 patients screened, 1,703 (56.9%) were not candidates for CTA because of prior cardiac disease (41%) or imaging contraindications (16%). Time to diagnosis (8.1 ± 8.5 vs. 9.4 ± 7.4 h) and length of hospital stay (19.7 ± 27.8 vs. 23.5 ± 34.4 h) were significantly shorter with CTA than with SPECT (P 5 0.002). However, time to diagnosis (7.0 ± 6.2 vs. 6.8 ± 5.9 h, P 5 0.20), length of stay (15.5 ± 17.2 vs. 16.7 ± 15.3 h, P 5 0.36), and hospital costs ($4,242 ± $3,871 vs. $4,364 ± 1781, P 5 0.86) were comparable with CTA versus SO SPECT, respectively. SO was also superior to conventional SPECT regarding all of the above metrics and significantly reduced radiation exposure (5.5 ± 4.4 vs. 12.5 ± 2.7 mSv, P , 0.0001). |
2 |
| 30. 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 Randomized Controlled CATCH Trial. JACC Cardiovasc Imaging. 8(12):1404-1413, 2015 Dec. |
Experimental-Dx |
576 patients |
To investigate the longterm clinical impact of a coronary computed tomographic angiography (CTA)-guided treatment strategy in patients with recent acute-onset chest pain compared to standard care. |
We randomized 299 patients to coronary CTA-guided strategy and 301 to standard care. After inclusion, 24 patients withdrew their consent. The median (interquartile range) follow-up duration was 18.7 (range 16.8 to 20.1) months. In the coronary CTA-guided group, 30 patients (11%) had a primary endpoint versus 47 patients (16%) in the standard care group (p = 0.04; hazard ratio [HR]: 0.62 [95% confidence interval: 0.40 to 0.98]). A major adverse cardiac event (cardiac death, MI, hospitalization for UAP, and late symptom-driven revascularization) was observed in 5 patients (2 MIs, 3 UAPs) in the coronary CTA-guided group versus 14 patients (1 cardiac death, 7 MIs, 5 UAPs, 1 late symptom-driven revascularization) in the standard care group (p = 0.04; HR: 0.36 [95% CI: 0.16 to 0.95]). Differences in cardiac death and MI (8 vs. 2) were insignificant (p = 0.06). |
2 |
| 31. Romero J, Husain SA, Holmes AA, et al. Non-invasive assessment of low risk acute chest pain in the emergency department: A comparative meta-analysis of prospective studies. Int J Cardiol. 187:565-80, 2015. |
Meta-analysis |
37 Studies (7800 Patients) |
To compare the diagnostic accuracy of cardiac computed tomographic angiography (CCTA), stress echocardiography (SE) and radionuclide single photon emission computed tomography (SPECT) for the assessment of chest pain in emergency department (ED) setting. |
Thirty-seven studies (15 CCTA, 9 SE, 13 SPECT) comprising a total of 7800 patients fulfilled inclusion criteria. The respective weighted mean sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and total diagnostic accuracy for CCTA were: 95%, 99%, 84%, 100% and 99%, for SE were: 84%, 94%, 73%, 96% and 96%, and for SPECT were: 85%, 86%, 57%, 95% and 88%. There was no significant difference between modalities in terms of NPV. Bivariate analysis revealed that CCTA had statistically greater sensitivity, specificity, PPV and overall diagnostic accuracy when compared to SE and SPECT. |
Inadequate |
| 32. Hulten E, Pickett C, Bittencourt MS, et al. Outcomes after coronary computed tomography angiography in the emergency department: a systematic review and meta-analysis of randomized, controlled trials. J Am Coll Cardiol. 61(8):880-92, 2013 Feb 26. |
Meta-analysis |
4 randomized control trials |
To systematically review and perform a meta-analysis of randomized, controlled trials of coronary computed tomography angiography (CCTA) versus usual care (UC) triage of acute chest pain in the emergency department (ED). |
Four randomized, controlled trials were included, with 1,869 patients undergoing CCTA and 1,397 undergoing UC. There were no deaths and no difference in the incidence of myocardial infarction, post-discharge ED visits, or rehospitalizations. Four studies reported decreased length of stay with CCTA and 3 reported cost savings; 8.4% of patients undergoing CCTA versus 6.3% of those receiving UC underwent invasive coronary angiography (ICA), whereas 4.6% of patients undergoing CCTA versus 2.6% of those receiving UC underwent coronary revascularization. The odds ratio of ICA for CCTA patients versus UC patients was 1.36 (95% confidence interval [CI]: 1.03 to 1.80, p = 0.030), and for revascularization, it was 1.81 (95% CI: 1.20 to 2.72, p = 0.004). The absolute increase in ICA after CCTA was 21 per 1,000 CCTA patients (95% CI: 1.8 to 44.9), and the number needed to scan was 48. The absolute increase in revascularization after CCTA was 20 per 1,000 patients (95% CI: 5.0 to 41.4); the number needed to scan was 50. Both percutaneous coronary intervention and coronary artery bypass graft surgery independently contributed to the significant increase in revascularization. |
Good |
| 33. Lardo AC, Rahsepar AA, Seo JH, et al. Estimating coronary blood flow using CT transluminal attenuation flow encoding: Formulation, preclinical validation, and clinical feasibility. Journal of cardiovascular computed tomography. 9(6):559-66.e1, 2015 Nov-Dec. |
Observational-Dx |
9 canine models and 39 acute chest pain patients |
To present the formulation and testing of a new CT angiography (CTA)-based method for noninvasive measurement of coronary blood flow (CBF) termed transluminal attenuation flow encoding (TAFE). |
In animal studies, TAFE-derived CBF in the left anterior descending, left circumflex, and right coronary artery was 20.8 ± 10.4 mL/min, 27.0 ± 13.4 mL/min, and 6.0 ± 3.7 mL/min, respectively. TAFEderived CBF divided by myocardial mass strongly correlated with microsphere myocardial blood flow (R2 ¼ 0.90, P < .001). In human studies, TAFE-derived CBF in the left anterior descending, left circumflex, and right coronary artery was 26.4 ± 10.7 mL/min, 20.1 ± 13.0 mL/min, and 43.2 ± 40.9 mL/min, respectively. CBF per unit mass was 0.93 ± 0.48 mL/g/min in patients. Interobserver variability was minimal with excellent correlation (R ¼ 0.96, P < .0001) and agreement (mean difference, 4.2 mL/min). |
4 |
| 34. Kitabata H, Leipsic J, Patel MR, et al. Incidence and predictors of lesion-specific ischemia by FFRCT: Learnings from the international ADVANCE registry. J Cardiovasc Comput Tomogr 2018;12:95-100. |
Review/Other-Dx |
1,000 patients |
To report the incidence of abnormal coronary computed tomography angiography (CTA)-derived fractional flow reserve (FFRCT) (=0.80) and the relationship of lesion-specific ischemia to subject demographics, symptoms, and degree of stenosis in the multicenter, prospective ADVANCE registry. |
FFRCT data were analyzed in 952 patients (95.2%). Overall, 51.1% patients had a positive FFRCT value (=0.80). Patients with =3 risk factors had a significantly higher rate of abnormal FFRCT than those with <3 risk factors (60.2% vs. 43.9%, p?=?0.0001). On multivariate analysis, baseline diabetes (odds ratio [OR] 1.52, 95% confidence interval [CI] 1.04–2.21, p?=?0.030) and hypertension (OR 1.56, 95%CI 1.14–2.14, p?=?0.005) were both predictive of abnormal FFRCT. In addition, >70% stenosis was significantly associated with low FFRCT (OR 31.16, 95%CI 12.25–79.22, p?<?0.0001) vs. <30% stenosis. Notably, stenosis 30–49% vs. <30% had an increased likelihood of ischemia (OR 3.74, 95%CI 1.52–9.17, p?<?0.0001). |
4 |
| 35. Pursnani A, Lee AM, Mayrhofer T, et al. Early resting myocardial computed tomography perfusion for the detection of acute coronary syndrome in patients with coronary artery disease. Circulation. Cardiovascular imaging. 8(3):e002404, 2015 Mar. |
Observational-Dx |
183 Patients |
To determine the diagnostic accuracy of early resting CTP (rCTP), the incremental value beyond obstructive coronary artery disease (CAD; =50% stenosis), and to compare early rCTP to late stress SPECT-MPI in patients with CAD presenting with suspicion of ACS to the emergency department. |
In this prespecified subanalysis of 183 patients (58.1±10.2 years; 33% women), we included patients with any CAD by coronary computed tomography angiography (CCTA) from Rule Out Myocardial Infarction Using Computer-Assisted Tomography I. rCTP was assessed semiquantitatively, blinded to CAD interpretation. Overall, 31 had ACS and 48 had abnormal rCTP. Sensitivity and specificity of rCTP for ACS were 48% (95% confidence interval [CI], 30%-67%) and 78% (95% CI, 71%-85%), respectively. rCTP predicted ACS (adjusted odds ratio, 3.40 [95% CI, 1.37-8.42]; P=0.008) independently of obstructive CAD, and sensitivity for ACS increased from 77% (95% CI, 59%-90%) for obstructive CAD to 90% (95% CI, 74%-98%) with addition of rCTP (P=0.05). In a subgroup undergoing late rest/stress SPECT-MPI (n=81), CCTA/rCTP had noninferior discriminatory value to CCTA/SPECT-MPI (area under the curve, 0.88 versus 0.90; P=0.64) using a noninferiority margin of 10%. |
2 |
| 36. Sorgaard M, Linde JJ, Hove JD, et al. Myocardial perfusion 320-row multidetector computed tomography-guided treatment strategy for the clinical management of patients with recent acute-onset chest pain: Design of the CArdiac cT in the treatment of acute CHest pain (CATCH)-2 randomized controlled trial. Am Heart J. 179:127-35, 2016 Sep. |
Review/Other-Dx |
N/A |
To describe the design of a randomized controlled trial, CATCH-2, comparing a clinical diagnostic management strategy of CCTA alone against CCTA in combination with CTP. |
No results stated in abstract. |
4 |
| 37. Burris AC 2nd, Boura JA, Raff GL, Chinnaiyan KM. Triple Rule Out Versus Coronary CT Angiography in Patients With Acute Chest Pain: Results From the ACIC Consortium. JACC Cardiovasc Imaging. 8(7):817-25, 2015 Jul. |
Observational-Dx |
12,834 patients |
To evaluate the diagnostic yield of triple rule out (TRO) versus coronary computed tomography angiography (CTA) scanning in patients with acute chest pain enrolled in a large statewide registry. |
From July 2007 to September 2013, 12,834 patients underwent computed tomography scanning (TRO, n = 1,555; coronary CTA, n = 11,279). The TRO group had more women (57.1% vs. 47.8%, p < 0.001). Diagnostic yield was similar (TRO, 17.4% vs. coronary CTA, 18.3%; p = 0.37), driven by CAD (15.5% vs. 17.2%, p = 0.093); PE and AD were 1.1% and 0.4% (p = 0.004) and 1.7% and 1.1% (p = 0.046). TRO had higher median radiation (9.1 mSv vs. 6.2 mSv; p < 0.0001) and mean contrast (113 ± 6 ml vs. 89 ± 17 ml; p < 0.0001) doses. Nondiagnostic images were frequent in TRO (9.4% vs. 6.5%; p < 0.0001). In emergency department patients, PE and AD were more often detected on TRO. Among inpatients, there were no differences in overall yield or in that of PE, AD, or CAD. |
3 |
| 38. Lehman SJ, Abbara S, Cury RC, et al. Significance of cardiac computed tomography incidental findings in acute chest pain. Am J Med. 2009;122(6):543-549. |
Review/Other-Dx |
395 patients |
To determine the prevalence and nature of incidental findings detected in patients presenting to the emergency department with ACP using a standard coronary CT acquisition protocol; determine the effect on in-hospital patient management; and project subsequent diagnostic testing. |
Incidental findings were detected in 44.8% (n=177): noncalcified pulmonary nodules (n=94, 23.8%), simple liver cysts (n=26, 6.6%), calcified pulmonary nodules (n=16, 4.1%), and contrast-enhancing liver lesions (n=9, 2.3%). In-hospital management was changed because of incidental finding reporting in 5 patients (1.3%), and a potential alternative diagnosis was offered in another 16 patients (4.1%). Subsequent diagnostic imaging tests were recommended in 81 patients (20.5%), including 74 chest CT scans. After 6 months, biopsy was performed in 3 patients, revealing cancer in 2 (0.5%) who underwent successful tumor resection. Clinically important findings are detected in up to 5% of patients with a lead symptom of ACP and low to intermediate likelihood of ACS, but only few directly change patient management; 21% are recommended for further imaging tests, resulting in invasive procedures and detection of cancer in few patients. |
4 |
| 39. Takx RAP, Vliegenthart R, Schoepf UJ, et al. Prognostic value of CT-derived left atrial and left ventricular measures in patients with acute chest pain. Eur J Radiol. 86:163-168, 2017 Jan. |
Observational-Dx |
225 patients |
To determine which left atrial (LA) and left ventricular (LV) parameters are associated with future major adverse cardiac event (MACE) and whether these measurements have independent prognostic value beyond risk factors and computed tomography (CT)-derived coronary artery disease measures. |
225 subjects (age, 56.2±11.2; 140 males) were analyzed, of whom 42 (18.7%) experienced a MACE during a median follow-up of 13 months. LA diameter (HR:1.07, 95%CI:1.01-1.13permm) and LV mass (HR:1.05, 95%CI:1.00-1.10perg) remained significant prognostic factor of MACE after controlling for Framingham risk score. LA diameter and LV mass were also found to have prognostic value independent of each other. The other morphologic and functional cardiac measures were no significant prognostic factors for MACE. |
4 |
| 40. Mussa FF, Horton JD, Moridzadeh R, Nicholson J, Trimarchi S, Eagle KA. Acute Aortic Dissection and Intramural Hematoma: A Systematic Review. [Review]. JAMA. 316(7):754-63, 2016 Aug 16. |
Review/Other-Dx |
82 Studies describing 57,311 patients |
To systematically review the current evidence on diagnosis and treatment of AAS. |
Chest or back pain was the most commonly reported presenting symptom of AAS (61.6%-84.8%). Patients were typically aged 60 to 70 years, male (50%-81%), and had hypertension (45%-100%). Sensitivities of computerized tomography and magnetic resonance imaging for diagnosis of AAS were 100% and 95% to 100%, respectively. Transesophageal echocardiography was 86% to 100% sensitive, whereas D-dimer was 51.7% to 100% sensitive and 32.8% to 89.2% specific among 6 studies (n?=?876). An immediate open surgical procedure is needed for dissection of the ascending aorta, given the high mortality (26%-58%) and proximity to the aortic valve and great vessels (with potential for dissection complications such as tamponade). An RCT comparing endovascular surgical procedure to medical management for uncomplicated AAS in the descending aorta (n?=?61) revealed no dissection-related deaths in either group. Endovascular surgical procedure was better than medical treatment (97% vs 43%, P?<?.001) for the primary end point of "favorable aortic remodeling" (false lumen thrombosis and no aortic dilation or rupture). The remaining evidence on therapies was observational, introducing significant selection bias. |
4 |
| 41. Saremi F.. Cardiac MR Imaging in Acute Coronary Syndrome: Application and Image Interpretation. [Review]. Radiology. 282(1):17-32, 2017 Jan. |
Review/Other-Dx |
N/A |
To introduce a brief explanation of the pathophysiology, classification, and treatment options for patients with ACS.To review indications of cardiac MR imaging in ACS patients and to discuss specific cardiac MR protocol, image interpretation, and potential diagnostic pitfalls. |
No abstract available. |
4 |
| 42. Friedrich MG, Sechtem U, Schulz-Menger J, et al. Cardiovascular magnetic resonance in myocarditis: A JACC White Paper. J Am Coll Cardiol. 2009;53(17):1475-1487. |
Review/Other-Dx |
N/A |
To review cardiovascular magnetic resonance in myocarditis. |
This work provides recommendations on the use of CMR as part of a comprehensive diagnostic approach in patients with suspected myocardial inflammation. The use of CMR appears suitable to identify patients with significant ongoing inflammation, which may be especially important for patients with recurrent or persisting symptoms and in patients with new onset heart failure. |
4 |
| 43. Haaf P, Garg P, Messroghli DR, Broadbent DA, Greenwood JP, Plein S. Cardiac T1 Mapping and Extracellular Volume (ECV) in clinical practice: a comprehensive review. [Review]. Journal of Cardiovascular Magnetic Resonance. 18(1):89, 2016 Nov 30. |
Review/Other-Dx |
N/A |
To review and illustrate advances in parametric mapping methods, in particular T1 mapping in cardiac diseases and to appraise their clinical potential in the context of established CMR methods. |
No results stated in abstract. |
4 |
| 44. Marwick TH, Cho I, O Hartaigh B, Min JK. Finding the Gatekeeper to the Cardiac Catheterization Laboratory: Coronary CT Angiography or Stress Testing?. [Review]. J Am Coll Cardiol. 65(25):2747-56, 2015 Jun 30. |
Review/Other-Dx |
N/A |
To discuss the review of finding the Gatekeeper to the Cardiac Catheterization Laboratory Coronary CT Angiography or Stress Testing |
The potential of CCTA to serve as an effective gatekeeper to invasive coronary angiography will depend, in part, on the adoption of these new developments, as well as definition of the benefit of detecting high-risk plaque for guiding the management of selected patients. |
4 |
| 45. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://www.acr.org/-/media/ACR/Files/Appropriateness-Criteria/RadiationDoseAssessmentIntro.pdf. |
Review/Other-Dx |
N/A |
To provide evidence-based guidelines on exposure of patients to ionizing radiation. |
No abstract available. |
4 |
