Clinician Update

Coronary Computed Tomographic Angiography

Its Role in Emergency Department Triage
Michael K. Cheezum, MD; Ron Blankstein, MD

ase presentation: A 55-year-old

man presents to the emergency
department (ED) after an episode of
substernal chest discomfort that lasted
2 hours. His pain occurred at rest and
was not positional, pleuritic, or postprandial. He has a history of hypertension and no known coronary artery
disease (CAD). Vital signs and physical examination are unremarkable. His
initial ECG, troponin, and serum creatinine are normal. How should this
patient be evaluated?

The Challenge of Evaluating

Acute Chest Pain
Chest pain is a common complaint in
the ED, accounting for 10% to 15% of
visits at an annual cost of $8 billion in
the United States.1 However, missed
myocardial infarctions occur in up to
2% of patients with acute chest pain2
and represent a leading cause of malpractice litigation. Because history
alone is often inadequate to identify
patients who may be safely discharged,3
it is common practice to use observation and serial cardiac biomarkers for
patient evaluation. Additionally, exercise testing and vasodilator stress testing are commonly used, although such

testing can be performed only after

an observation period, which includes
serial cardiac biomarkers. With
increasing use of cardiac testing in
an era of cost containment, a growing
need exists to improve the efficiency
and cost associated with the evaluation
of acute chest pain.

Coronary Computed
Tomographic Angiography:
A Rapid Alternative
to Usual Care
Coronary computed tomographic (CT)
angiography (CTA) is a high-resolution,
noninvasive technique to image the coronary arteries and to detect the presence,
severity, and extent of CAD.4 The greatest utility of CTA lies in its high negative predictive value (95%) to exclude
obstructive CAD and thus to identify
patients who can be safely discharged
without further diagnostic testing.5 In
addition, this test can be performed
rapidly because only 1 set of negative
biomarkers is needed. Consequently, 4
randomized, controlled trials in the ED
have compared CTA with usual care68
and single-photon emission CT,9 demonstrating a consistent ability of CTA
to expedite discharge.10 Reassuringly,

patients with a normal CTA or minimal

CAD had very low downstream adverse
cardiac events (<1%/y).

Strengths and Limitations

Although CTA avoids the inherent
risks of stress testing in patients with
suspected acute coronary syndrome
(ACS), there are several strengths
and limitations to consider (Table 1).
Contrast and radiation remain potential concerns, but advances in CT
hardware and software have improved
overall patient safety. For instance,
with prospective gated ECG triggering, the average effective dose is 3 to
4 mSv, equivalent to the annual level
of background radiation from natural
sources. Despite these advances, alternative tests (eg, treadmill testing, stress
echocardiography) remain reasonable
options in selected patients.

Patient Selection
The initial evaluation of acute chest
pain requires an ECG and cardiac
biomarkers (Figure1A).11 Patients at
very low risk for CAD and those with
an alternative explanation for their
symptoms require no further testing.
Conversely, those with a high pretest
probability for CAD may benefit from

From the Departments of Medicine (Cardiovascular Division) and Radiology, Brigham and Womens Hospital, Boston MA.
Correspondence to Ron Blankstein, MD, FACC, Brigham and Womens Hospital, Non-Invasive Cardiovascular Imaging Program, Departments of
Medicine (Cardiovascular Division) and Radiology, 75 Francis St, Boston MA 02115. E-mail rblankstein@partners.org
(Circulation. 2014;130:2052-2056.)
2014 American Heart Association, Inc.
Circulation is available at http://circ.ahajournals.org

DOI: 10.1161/CIRCULATIONAHA.114.009648

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2052

Cheezum and Blankstein Role of CTA in ED Triage 2053

Table 1. Strengths and Limitations of

CTA for Acute Chest Pain
Limitations

administration. Unless contraindicated,

all patients receive nitroglycerin before
scanning.

Is noninvasive

Significance of anatomic
lesions may be unknown

Management of CTA Findings

Detects the full

spectrum of CAD

Incidental findings may

require further workup

May affect preventive

therapies

Intravenous contrast

Strengths

Lowers ED cost relative Radiation

to usual care
Decreases time to
diagnosis and length
of stay

May increase
downstream costs and
revascularizations

Evaluates other causes Limited quality if

of chest pain
elevated heart rate,
arrhythmias, or morbid
obesity is present

Normal CTA: No Plaque or

Stenosis
Patients with normal CTA may be safely
discharged and have an extremely low
cardiac event rate (Figure1B).

Nonobstructive CAD
In patients with nonobstructive CAD,
a small potential for ACS remains
despite the absence of significant stenosis. In the Rule Out Myocardial
Infarction Using Computer Assisted
Tomography (ROMICAT) I trial, in
which providers were blinded to all
CTA results, 6% of patients with nonobstructive CAD were ultimately categorized as having ACS, including 3
patients with myocardial infarction

CAD indicates coronary artery disease; CTA,

computed tomographic angiography; and ED,
emergency department.

a functional strategy (eg, myocardial

perfusion imaging or stress echocardiography) because CTA has reduced
specificity to detect ischemia.12
Thus, ideal candidates for CTA are
patients at low to intermediate risk of
obstructive CAD (Figure2).5 In addition, the use of CTA in the ED requires
careful consideration of several key
clinical, patient, and institutional factors (Table2).
Beyond risk prediction for obstructive CAD, several scores are available
to stratify patients for ACS risk and
potential complications but have limited sensitivity to exclude ACS. Among
available ED studies, 2 have used a
Thrombolysis in Myocardial Infarction
(TIMI) risk score of 2 or 4 among
clinical features (eg, history, ECG, biomarkers) to select potential candidates
for CTA.8,9

Patient Preparation
In patients selected to undergo CTA,
preparation with -blockers and breathing instructions are paramount for
achieving high image quality, although
some scanners now permit rapid image
acquisition, obviating the need for
aggressive heart rate control. Largebore (18 gauge) intravenous access
is preferred for high-flow contrast

Figure 1. A, Proposed testing strategy in patients with possible acute coronary syndrome
(ACS). *Contraindications to computed tomographic angiography (CTA) include renal
disease, severe allergy to iodine contrast, inability to follow breath-hold instructions, and
pregnancy. Also consider factors that may impair image quality: body mass index >40
kg/m2, arrhythmias, high heart rate despite -blockers, extensive coronary calcifications,
and intolerance or contraindication to -blockers or nitroglycerin. Adapted from Cheezum
et al11 with permission from the publisher. Copyright 2014 Informa Plc. Authorization
for this adaptation has been obtained both from the owner of the copyright in the original
work and from the owner of copyright in the translation or adaptation. B, Early imaging
strategy implementing coronary CTA. CAD indicates coronary artery disease. Adapted
from Cheezum et al11 with permission from the publisher. Copyright 2014 Informa Plc.
Authorization for this adaptation has been obtained both from the owner of the copyright
in the original work and from the owner of copyright in the translation or adaptation.

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2054CirculationDecember 2, 2014

set of biomarkers. If negative, such

patients can be discharged but require
outpatient follow-up for preventive
care (Figure1B).

Obstructive CAD

Figure 2. The 2010 computed

tomographic angiography (CTA)
appropriate use criteria in patients with
acute chest pain. CAD indicates coronary
artery disease; and MI, myocardial
infarction. Adapted from Taylor et al.5

who had a positive second set of cardiac biomarkers.13 Nevertheless, 2 subsequent randomized, controlled trials
have demonstrated a very low event
rate when patients with nonobstructive
CTA findings were immediately discharged. On the basis of the available
data, a conservative approach among
patients who are found to have nonobstructive plaque is to check a second

In patients with obstructive CAD,

admission and further workup are
recommended to guide management.
For the majority of these patients, particularly those with moderate stenosis
(ie, 50%70%), functional testing for
ischemia (noninvasive or invasive) is
recommended because it may reduce
unnecessary coronary revascularizations (Figure1B).

CTA to Guide Preventive

Therapy
Patients with both nonobstructive and
obstructive CAD have increased risk
for long-term major adverse cardiac
events relative to patients with no
CAD. For example, among patients
with nonobstructive plaque, the 2-year

Table 2. Factors Influencing Testing Strategy

Examples

Favors CTA

Exclude CAD

Favors Functional
Testing

Clinical factors

What is the clinical
question?

Exclude ischemia

Identify future risk of adverse cardiac

events...
To guide preventive therapies


Is there an alternative
diagnosis that may account
for patient symptoms?

To guide revascularization

Evaluate physiological response to

exercise

Hiatal hernia, aortopathy, lung disease,

pulmonary embolism

Valvular disease, pericarditis

Patient factors

Pretest probability of CAD

Ability to obtain diagnostic
CTA image quality

Contraindications to CTA

Low to intermediate risk

High risk, known CAD, prior PCI/CABG

High heart rate, arrhythmias, extensive

coronary calcification, inability to hold
breath, morbid obesity

Kidney dysfunction, iodine allergy,

pregnancy

Institutional factors (experience, availability, local reimbursement policy)

ACS indicates acute coronary syndrome; CABG, coronary artery bypass grafting; CAD, coronary artery
disease; CTA, computed tomographic angiography; and PCI, percutaneous coronary intervention.
*Depending on the type of functional testing performed (eg, magnetic resonance imaging is best for
evaluating pericardial disease; echocardiography may be useful when valvular disease is suspected).

cardiac event rate in ROMICAT I was

4.6% (1.2% after excluding early [<30
day] major adverse cardiac events)
versus 0% for patients with no CAD.14
Similarly, other studies have demonstrated that nonobstructive plaque on
CTA, especially when multiple segments are involved, is associated with
a higher rate of hard cardiovascular
events compared with no plaque on
CTA.4 Supporting the growing recognition that coronary plaque on CTA
is associated with an increased event
rate, multiple observational studies
have shown that CTA is associated
with intensification in preventive therapies and modification of CVD risk
factors.15,16

Unanswered Questions
What is the Long-Term CostEffectiveness of CTA Relative to
Usual Care?
Although CTA has been shown to
reduce ED costs compared with usual
care, available studies have shown
no benefit in total hospital costs with
CTA use. As a test designed to detect
the anatomic presence of CAD, CTA
has potential to increase downstream
costs by unnecessarily triggering
invasive angiography and coronary revascularization procedures.
Although further research is needed
to clarify the cost benefit of CTA,
data suggest that when the prevalence
or inability to exclude obstructive
CAD is <30%, CTA offers cost savings relative to usual care for acute
chest pain.17

Can Coronary Artery

Calcification Testing Alone
Safely Exclude ACS in Low-Risk
Patients?
Coronary artery calcification (CAC)
testing alone has been proposed as
a rapid, inexpensive test that is easy
to perform and can exclude ACS in
a majority of low-risk symptomatic patients.18 National Institute
for Health and Clinical Excellence
guidelines have adopted this strategy on the basis of estimates of the
cost-effectiveness of this approach, 19

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Cheezum and Blankstein Role of CTA in ED Triage 2055

Case Resolution
Given the intermediate pretest probability of obstructive CAD and the absence
of contraindications, the patient underwent CTA, demonstrating mild nonobstructive CAD (Figure3). A second set
of cardiac biomarkers was normal. He
was discharged with follow-up for risk
factor management and has remained
free of adverse cardiac events.

Disclosures
None. The views expressed here are those
of the authors only.
Figure 3. Coronary computed tomographic angiography (CTA) demonstrating
nonobstructive coronary artery disease. Top row, Three-dimensional and curved
multiplanar views of the left anterior descending artery (LAD), left circumflex artery (LCX),
and right coronary artery (RCA). There is noncalcified and calcified plaque in the proximal
and mid-LAD, resulting in mild (25%49%) stenosis. Bottom row, Orthogonal and shortaxis views of mid-LAD demonstrating (b) predominant calcified plaque in the mid-LAD,
resulting in mild (25%49%) stenosis relative to (a) proximal and (c) distal reference
vessels.

yet research and widespread use of

CAC alone in symptomatic patients
remain limited. Although data support favorable prognosis among
patients with CAC of zero, 20 further
studies are needed to examine the
safety of CAC for ruling out ACS
and potentially to guide the need
and type of further testing (eg, discharge when CAC=0, CTA when
CAC=199, and perfusion imaging
for patients with CAC >100).

Is There a Role for Triple RuleOut Scanning?

Of relevance to the ED setting is the
potential for CTA use as a triple ruleout (TRO) test to simultaneously
exclude ACS, aortic dissection, and
pulmonary embolism. Challenges to
TRO use have limited its widespread
application, with data suggesting that
the rate of pulmonary embolism and
aortic dissection detected by TRO
testing is very low (1% of scans).21
Additionally, TRO scans require more
contrast to opacify all 3 vascular beds
with higher radiation doses compared
with CTA. Although newer scanners
and techniques should improve the riskto-benefit ratio of TRO, appropriate use
of TRO scanning remains uncertain.5

What Is the Role of HighSensitivity Troponin Among

Testing Strategies?
Initial studies have demonstrated a high
accuracy for high-sensitivity troponin
(c statistic=0.94) to exclude ACS in the
first hour of presentation, with an ability to predict ischemia and CAD burden among patients with normal initial
standard troponin levels.22 Although
studies have shown that high-sensitivity troponin may offer prognostic value
independently of CTA findings, its
specificity for ACS appears to be more
limited.23 Further research is needed to
define the role of high-sensitivity troponin among available strategies.

Conclusions
Coronary CTA is now an established,
noninvasive technique that can rapidly
exclude obstructive CAD and identify
patients who can be safely discharged
from the ED. Although CTA appears to
lower ED costs and may lead to intensification in preventive therapies, concern
remains about the potential for this test
to increase invasive angiography and
coronary revascularizations. Ultimately,
appropriate patient selection will remain
essential for ensuring optimal test use
and patient management.

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Coronary Computed Tomographic Angiography: Its Role in Emergency Department

Triage
Michael K. Cheezum and Ron Blankstein
Circulation. 2014;130:2052-2056
doi: 10.1161/CIRCULATIONAHA.114.009648
Circulation is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231
Copyright 2014 American Heart Association, Inc. All rights reserved.
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