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Late Outcomes of Patients in the Emergency Department With Acute Chest Pain Evaluated With Computed
Jason Schott1, Olivia Allen1, Zachary Rollins1
1Department of Cardiovascular Medicine, William Beaumont University Hospital-Corewell Health East, Royal Oak, Michigan.
Insights
Fractional flow reserve computed tomography (FFRCT) safely triages patients with acute chest pain in the emergency department (ACP-ED). Negative FFRCT indicates an excellent long-term prognosis, while positive FFRCT identifies obstructive disease needing intervention.
Area of Science:
- Cardiology
- Medical Imaging
- Diagnostic Tools
Background:
- Computed tomography (CTA)-derived fractional flow reserve (FFRCT) is used to guide invasive coronary angiography (ICA).
- Late outcomes after FFRCT are established in stable ischemic heart disease but not in acute chest pain in the emergency department (ACP-ED).
Purpose of the Study:
- To assess the risk of death, myocardial infarction (MI), revascularization, and ICA following FFRCT in low-risk ACP-ED patients.
- To evaluate the prognostic value of FFRCT in this patient population.
Main Methods:
- A prospective registry included 389 low-risk ACP-ED patients who underwent CTA and FFRCT (2015-2018).
- Patients were followed for 41 ± 10 months to track clinical outcomes.
- Outcomes included death, MI, revascularization, and ICA, with revascularization appropriateness adjudicated.
Main Results:
- Positive FFRCT (≤0.80) was found in 32% of patients, leading to higher rates of ICA (87%) and revascularization (70%) compared to negative FFRCT (34% ICA, 8% revascularization).
- Appropriate revascularization was significantly higher in positive FFRCT patients (65%) versus negative (2%).
- Late outcomes were low: 0.2% death and 0.7% MI in the overall cohort.
Conclusions:
- FFRCT can safely triage low-risk ACP-ED patients, identifying those with obstructive coronary artery disease.
- Negative FFRCT is associated with an excellent long-term prognosis, minimizing the need for further invasive procedures.
- FFRCT effectively reduces unnecessary invasive coronary angiography and revascularization in the emergency department setting.
Abstract:
Computed tomography (CTA)-derived fractional flow reserve (FFRCT) guides the need for invasive coronary angiography (ICA). Late outcomes after FFRCT are reported in stable ischemic heart disease but not in acute chest pain in the emergency department (ACP-ED). The objectives are to assess the risk of death, myocardial infarction (MI), revascularization, and ICA after FFRCT. From 2015 to 2018, 389 low-risk patients with ACP-ED (negative biomarkers, no electrocardiographic ischemia) underwent CTA and FFRCT and were entered into a prospective institutional registry; patients were followed up for 41 ± 10 months. CTA stenosis ≥50% was present in 81% of the patients. Positive (FFRCT ≤0.80) and negative FFRCT were observed in 124 (32%) and 265 patients (68%), respectively. ICA was performed in 108 of 124 patients (87%) with positive FFRCT and 89 of 265 patients (34%) with negative FFRCT (p <0.00001). Revascularization was performed in 87 of 124 (70%) patients with positive FFRCT and in 22 of 265 (8%) with negative FFRCT (p <0.00001). Appropriateness of revascularization was established by blinded adjudication of ICA and invasive FFR using practice guidelines; revascularization was appropriate in 81 of 124 (65%) and 6 of 265 (2%) of FFRCT-positive and -negative patients, respectively (p <0.00001). At follow-up, for patients with positive versus negative FFRCT, the rates were 0.8% versus 0% for death (p = 0.32) and 1.6% versus 0.4% for MI (p = 0.24). In conclusion, in low-risk patients with ACP-ED who underwent CTA and FFRCT, the risk of late death (0.2%) and MI (0.7%) are low. Negative FFRCT is associated with excellent long-term prognosis, and positive FFRCT predicts obstructive disease requiring revascularization. FFRCT can safely triage patients with ACP-ED and reduce unnecessary ICA and revascularization.
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