CCTA assessment in acute coronary syndromes-do we

have time for it in the emergency settings?

Abstract
Acute coronary syndrome (ACS) diagnosis and therapeutical approach remain a
challenge for the clinicians even more when we talking about patients at low to interme-
diate risk. Due to its high specificity and sensitivity of Coronary computed tomography
angiography (CCTA) in detecting significant coronary stenosis, this procedure tends to
be more frequently used in the Emergency Department (ED), increasing the rates for
safe discharged of the patients with chest pain, less time spending in the ED, decreased
costs related to further investigations. CCTA can evaluate accurately the indication for
percutaneous coronary angioplasty and can offer important characteristics of the coro-
nary plaques being able to detect vulnerable sessions that need further approach.
The aim of this manuscript is to highlight the possibility of use of CCTA in ED in the as-
sessment of the patients with acute coronary syndrome and to show the benefits of the
procedure regarding safety, costs, accuracy, time, found in the most recent publications.
Keywords: Coronary computed tomography angiography, acute coronary syndrome,
emergency department
Background
Coronary computed tomography angiography became a widely used imagistic
technique, due to its high specificity and accuracy for detecting coronary artery diseases
(CAD) but also because it`s widely availability, providing important data regarding coro-
nary anatomy, calcium scoring, coronary lumen, plaques characteristics all of these
without being an invasive procedure.1 It is frequently used in the emergency depart-
ment, being a reliable procedure that allows the clinician to safely discharge the patients
with suspected acute coronary syndrome.2,3
Acute coronary syndrome remains a major cause of mortality world wide even if
many developments were done in this field.4 This pathology includes acute myocardial
infarction and unstable angina. According to data published by American Heart Associa-
tion approximately 1,5 million of patients were discharged in 2005 in USA with ACS.5
Recent data regarding ACS shows that annually 7 million deaths occurs due to ischemic
heart diseases and a number of 129 million of patients present loss of disability-ad-
justed life years (DALYs) annually worldwide after a coronary ischemic event.6,7
CCTA can offer details regarding the patient`s condition being an important pro-
cedure in the setting of acute chest pain in the emergency department, for the patients
evaluated at low to intermediate risk.8 A negative scan test could help the physician to
safely discharge the patients who were admitted at the ED for chest pain, and data
available showed that also have a high predictive value for favorable outcome at 1 year
follow-up.9CCTA is evaluated with a sensitivity and specificity ranging from 91%to 99%
and 74% to 96%, similar results emphasized in many studies.10-14 One important clinical
study ACCURACY based on patients with coronary artery diseases and stable angina
showed that the diagnosis offered by CCTA has high accuracy having a great perfor-
mance to evaluate a coronary stenosis.15 Another multi center study in which were en-
rolled 360 patients with acute stable angina but also unstable and found similar per-
centage for the sensitivity and specificity of the imagistic procedure, 99%,64% respec-
tively.16
Many researchers showed in their manuscripts that CCTA can offer an accurate
diagnosis and emphasized its high specificity and sensitivity. Almost all of these studies
also mentioned above, offer data regarding patients with stable angina. Thus came a
logical question if it can be used in the evaluation of the patients with acute coronary
syndromes that are examined at the ED. What could be the benefits for the patients to
undergo firstly this noninvasive imagistic procedure, and finally the question is if there is
enough time for the procedure, these are a few questions that will be debated in this
manuscript.

CCTA in the evaluation of the patients with ACS without ST-elevation seg-
ment
Due to lack of effective protocols for ACS without ST-elevation segment in pa-
tients at low to intermediate risk, CCTA could be an integrated procedure for the pa-
tients presenting at the ED for unstable angina. For instance, Meijboom et al. studied
this fact on 104 patients with ACS without ST-elevation segment, for whom CCTA was
performed and traditional coronary angiography. The result were compared, and CCTA
seemed to have high sensitivity -100% in diagnosing the significant coronary stenosis.17
Hoffmann et al. reported similar results in their study in which examined 103 pa-
tients who were admitted at ED for acute chest pain. They also observed in their study
the time consuming for the entire procedure, so they found that almost 35 minutes can
take the preparing of the patient the scan time and the interpretation time. Overall 14 of
the patients had ACS and for the rest of the patients ACS was rule out, being safely dis-
charged.5 of the patients had myocardial infarction and they underwent PCI immedi-
ately.They found a good negative predictability of the procedure.18
Another study that showed a high sensitivity of CCTA is ROMICAT study. It in-
volved 368 patients with chest pain with low to intermediate risk for ACS. Half of them
didn't have any coronary lesions and CCTA helped in reducing the time spending for
further investigations and also reduced the cost for unnecessary hospitalization.19% of
the patients were evaluated according to CTA characteristics with significative coronary
stenosis.At 2 year follow up the researchers found that 6.8% of the patients had acute
myocardial infarction or needed coronary revascularizations. Therefore CCTA had a
high prognostic value in detecting the probability of major cardiac events (MACE) in the
follow-up period.19
Motoyama et al. evaluated in their study the CT characteristics of lesions causing
ACS. They examined 38 patients with ACS and compared with 33 patients diagnosed
with stable angina pectoris. They found that positive vascular remodeling, low plaque
density lower than 30 HU and spotty calcifications are characteristics for plaques asso-
ciated with acute ischemic events.20

Benefits of CCTA in acute setting

 CCTA could be a reliable diagnostic procedure in patients with ACS who are ad-
mitted at ED who should perform stress tests for a doubtful diagnosis, so CCTA could
replace stress test that sometimes is difficult to be interpreted and can cause misunder-
standings.17
An important aspect should be mentioned, the patients who are admitted at ED for
chest pain and the Electrocardiogram ECG shows ST-elevation segment should un-
dergo PCI as soon as possible, in this situation performing a CCTA can be time con-
suming, and the time is important for the outcome of the patient.21 However, CCTA can
rule out multivessel disease (MVD ), or unsuitable anatomy for PCI that requires Coro-
nary Bypass Surgery (CABG) in acute phase of STEMI. An urgent need for CABG is
also carcinogenic shock associated with unsuitable anatomy not amendable for PCI,
that CCTA can rule out. These are still a few patients that were described in the litera-
ture. 22
Litt et al.published a multicenter study in which they enrolled 1392 patients with
suspected ACS who were admitted at ED for acute chest pain. They randomized the
patients in 2 groups, first group consisted of patients who underwent CCTA and second
group patients that were investigated with traditional care. They compared the two
groups, and found that the patients who underwent CCTA were discharged from the ED
in less time, consisted in a percentage of 49,6% vs 22,7% that contained discharged
patients from the traditional care group. Moreover, coronary artery disease was diag-
nosed in a high percentage in the CCTA group than in the second group: 9,9% vs 3,5%.
They concluded that CCTA can be safely included in the protocols of the ED for sus-
pected acute coronary syndromes in patients at low to intermediate risk.3
Hulten et al. performed a systematic meta-analysis in which evaluated the accu-
racy of CCTA in acute setting in the ED for the patients with suspected ACS. They in-
cluded in their analysis studies 3,23,24,25, which compared the outcome of the patients
evaluated with CCTA and usual care. They observed that compared to usual care, pa-
tients who performed CCTA required less costs and decreased length of stay in the
hospital, moreover the CCTA group consisted patients who required PCI and revascu-
larization 4,6%more than usual care group,2,6% that was interpreting the usual care
can not always rule out CAD and misdiagnosed it.Also they studied the time consumed
to diagnosis, that was reduced with 15,3-18,1% in CCTA group than usual care group.26
For high accuracy and easy interpretation of the images, the patients should be pre-
pared according to CCTA protocol, with stable heart rate. 27

Conclusion
CCTA can be used in emergency setting for the evaluation of patients with acute coro-
nary syndrome assessed at low to intermediate risk, without ST elevation segment seen
on ECG. Using this procedure can be decreased the time spent of the patients in the
ED, the costs associated with additional investigations, but also can decrease the time
to diagnosis. It has high accuracy in detecting significant coronary stenosis and can
evaluate the proper way of treatment and follow up of the patients with suspected acute
coronary syndrome.
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