Coronary CT Angiography in Patients With Non-ST-Segment Elevation Acute Coronary Syndrome
Jesper J Linde1, Henning Kelbæk2, Thomas F Hansen3
1Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
Insights
Coronary computed tomography angiography (CTA) accurately rules out significant coronary artery disease in non-ST-segment elevation acute coronary syndrome (NSTEACS) patients. This diagnostic tool demonstrated high negative predictive value, aiding in clinical decision-making for NSTEACS management.
Area of Science:
- Cardiology
- Radiology
- Medical Imaging
Background:
- Non-ST-segment elevation acute coronary syndrome (NSTEACS) presents a spectrum of coronary pathologies.
- Accurate assessment of coronary artery disease is crucial for NSTEACS patient management.
Purpose of the Study:
- To evaluate the efficacy of coronary computed tomography angiography (CTA) in excluding significant coronary artery stenosis (≥50%) in NSTEACS patients.
- To determine the negative predictive value (NPV) of coronary CTA using invasive coronary angiography (ICA) as the reference standard.
Main Methods:
- The VERDICT trial included a blinded observational component where coronary CTA was performed before ICA in NSTEACS patients.
- A total of 1,023 patients underwent coronary CTA, with randomization to very early or standard invasive strategies.
- The primary endpoint was the NPV of coronary CTA for detecting ≥50% stenosis.
Main Results:
- Coronary CTA identified ≥50% stenosis in 68.9% of patients, compared to 67.4% by ICA.
- The per-patient NPV of coronary CTA was 90.9% (95% CI: 86.8% to 94.1%).
- Sensitivity was 96.5% and specificity was 72.4%, with a positive predictive value of 87.9%.
Conclusions:
- Coronary CTA demonstrates high diagnostic accuracy for ruling out significant coronary artery disease in NSTEACS.
- The NPV of coronary CTA was not affected by patient characteristics or clinical risk profiles.
- Findings support the use of coronary CTA as a reliable tool in the diagnostic workup of NSTEACS.
Background:
In patients with non-ST-segment elevation acute coronary syndrome (NSTEACS), coronary pathology may range from structurally normal vessels to severe coronary artery disease.
Objectives:
The purpose of this study was to test if coronary computed tomography angiography (CTA) may be used to exclude coronary artery stenosis ≥50% in patients with NSTEACS.
Methods:
The VERDICT (Very Early Versus Deferred Invasive Evaluation Using Computerized Tomography in Patients With Acute Coronary Syndromes) trial (NCT02061891) evaluated the outcome of patients with confirmed NSTEACS randomized 1:1 to very early (within 12 h) or standard (48 to 72 h) invasive coronary angiography (ICA). As an observational component of the trial, a clinically blinded coronary CTA was conducted prior to ICA in both groups. The primary endpoint was the ability of coronary CTA to rule out coronary artery stenosis (≥50% stenosis) in the entire population, expressed as the negative predictive value (NPV), using ICA as the reference standard.
Results:
Coronary CTA was conducted in 1,023 patients-very early, 2.5 h (interquartile range [IQR]: 1.8 to 4.2 h), n = 583; and standard, 59.9 h (IQR: 38.9 to 86.7 h); n = 440 after the diagnosis of NSTEACS was made. A coronary stenosis ≥50% was found by coronary CTA in 68.9% and by ICA in 67.4% of the patients. Per-patient NPV of coronary CTA was 90.9% (95% confidence interval [CI]: 86.8% to 94.1%) and the positive predictive value, sensitivity, and specificity were 87.9% (95% CI: 85.3% to 90.1%), 96.5% (95% CI: 94.9% to 97.8%) and 72.4% (95% CI: 67.2% to 77.1%), respectively. NPV was not influenced by patient characteristics or clinical risk profile and was similar in the very early and the standard strategy group.
Conclusions:
Coronary CTA has a high diagnostic accuracy to rule out clinically significant coronary artery disease in patients with NSTEACS.
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