High-risk plaques detected on coronary CTA significantly predicted acute coronary syndromes independent of significant stenosis (OR 8.9; 95% CI 1.8-43.3; p=0.006).
RCT (n=472)
randomized
Yes
Does the presence of high-risk plaque on coronary CTA predict acute coronary syndromes independently of significant stenosis in patients with acute chest pain?
In patients with acute chest pain and negative initial ECG/troponin, high-risk plaque features on coronary CTA independently predict ACS, providing incremental diagnostic value beyond stenosis severity.
Odds Ratio: 8.9 (95% CI 1.8–43.3)
p-value: p=0.006
BACKGROUND: It is not known whether high-risk plaque, as detected by coronary computed tomography angiography (CTA), permits improved early diagnosis of acute coronary syndromes (ACS) independently to the presence of significant coronary artery disease (CAD) in patients with acute chest pain. OBJECTIVES: The primary aim of this study was to determine whether high-risk plaque features, as detected by CTA in the emergency department (ED), may improve diagnostic certainty of ACS independently and incrementally to the presence of significant CAD and clinical risk assessment in patients with acute chest pain but without objective evidence of myocardial ischemia or myocardial infarction (MI). METHODS: We included patients randomized to the coronary CTA arm of the ROMICAT-II (Rule Out Myocardial Infarction/Ischemia Using Computer-Assisted Tomography II) trial. Readers assessed coronary CTA qualitatively for the presence of nonobstructive CAD (1% to 49% stenosis), significant CAD (≥50% or ≥70% stenosis), and the presence of at least 1 of the high-risk plaque features (positive remodeling, low <30 Hounsfield units plaque, napkin-ring sign, spotty calcium). In logistic regression analysis, we determined the association of high-risk plaque with ACS (MI or unstable angina pectoris) during the index hospitalization and whether this was independent of significant CAD and clinical risk assessment. RESULTS: Overall, 37 of 472 patients who underwent coronary CTA with diagnostic image quality (mean age 53.9 ± 8.0 years; 52.8% men) had ACS (7.8%; MI n = 5; unstable angina pectoris n = 32). CAD was present in 262 patients (55.5%; nonobstructive CAD in 217 patients 46.0% and significant CAD with ≥50% stenosis in 45 patients 9.5%). High-risk plaques were more frequent in patients with ACS and remained a significant predictor of ACS (odds ratio OR: 8.9; 95% CI: 1.8 to 43.3; p = 0.006) after adjustment for ≥50% stenosis (OR: 38.6; 95% CI: 14.2 to 104.7; p < 0.001) and clinical risk assessment (age, sex, number of cardiovascular risk factors). Similar results were observed after adjustment for ≥70% stenosis. CONCLUSIONS: In patients presenting to the ED with acute chest pain but negative initial electrocardiogram and troponin, presence of high-risk plaques on coronary CTA increased the likelihood of ACS independent of significant CAD and clinical risk assessment (age, sex, and number of cardiovascular risk factors). (Multicenter Study to Rule Out Myocardial Infarction by Cardiac Computed Tomography ROMICAT-II; NCT01084239).
Puchner et al. (2014) conducted an RCT in Acute chest pain (n=472). High-risk plaque detected on coronary CTA vs. Absence of high-risk plaque was evaluated on Acute coronary syndromes (myocardial infarction or unstable angina pectoris) during the index hospitalization (OR 8.9, 95% CI 1.8 to 43.3, p=0.006). High-risk plaques detected on coronary CTA significantly predicted acute coronary syndromes independent of significant stenosis (OR 8.9; 95% CI 1.8-43.3; p=0.006).