Coronary artery disease progression in patients without significant stenosis on coronary computed tomographic angiography

• Published in: The American journal of emergency medicine Vol. 30; no. 9; pp. 2015 - 2020
• Main Authors: Chang, Anna Marie, MD, Ginty, Catherine T., MD, Litt, Harold I., MD, PhD, Hollander, Judd E., MD
• Format: Journal Article
• Language: English
• Published: New York, NY Elsevier Inc 01-11-2012; Elsevier; Elsevier Limited
• Subjects: Acute coronary syndromes; Adult; Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Aneurysms; Biological and medical sciences; Cardiac catheterization; Cardiac stress tests; Cardiology. Vascular system; Cardiovascular disease; Computed tomography; Coronary Angiography; Coronary Artery Disease - diagnostic imaging; Coronary Artery Disease - pathology; Coronary heart disease; Coronary Stenosis - diagnostic imaging; Coronary Stenosis - pathology; Coronary vessels; Coronary Vessels - diagnostic imaging; Coronary Vessels - pathology; Disease Progression; Emergency; Emergency medical care; Emergency medical services; Female; Heart; Humans; Intensive care medicine; Intubation; Male; Medical imaging; Medical records; Medical sciences; Middle Aged; Myocardial infarction; Retrospective Studies; Time Factors; Tomography, X-Ray Computed; Human; Intensive care; Stenosis; Cardiovascular disease; Coronary arteriography; Angiocomputed tomography; Coronary heart disease; Resuscitation
• ISSN: 0735-6757; 1532-8171
• DOI: 10.1016/j.ajem.2012.03.018

Abstract Background Patients who present to the emergency department (ED) with symptoms of potential acute coronary syndrome (ACS) can be safely discharged home after a coronary computed tomographic angiography (CTA) with a negative result. However, the duration of time for which a negative coronary CTA scan result can be used to inform decision making when patients have recurrent symptoms is not known. Objective We examined patients who received more than 1 coronary CTA for evaluation of ACS to determine whether they had disease progression. Our main outcome was whether any patient had a maximal stenosis cross the threshold from noncritical (<50% maximal stenosis) to potentially critical disease. Methods We performed a structured comprehensive record search of all coronary CTAs performed from 2005 to 2010 at a tertiary care health system. Low-to-intermediate risk ED patients who received 2 or more coronary CTAs, at least 1 from an ED evaluation for potential ACS, were identified. Patients who were revascularized between scans were excluded. We collected demographic data, clinical course, time between scans, and number of ED visits between scans. Record review was structured and done by trained abstractors. Our main outcome was progression of coronary stenosis between scans, specifically crossing the threshold from noncritical to potentially critical disease. Results Overall, 32 patients who received repeat imaging were identified (median age, 45 years; interquartile range, 37.5-48; 56% female; 88% black). The median time between studies was 27.3 months (interquartile range, 18.2-33.2). Twenty-two patients did not have stenosis in any vessel on either coronary CTA, 2 studies showed increasing stenosis of less than 20%, and the rest showed “improvement” due to better imaging quality. No patient initially below the 50% threshold subsequently exceeded it (0%; 95% confidence interval, 0-11.0%). No patient had acute myocardial infarction or revascularization either between scans or within a year after the repeated imaging. Conclusion Repeated imaging potentially may not be warranted within 2 years of a negative coronary CTA result. The low rate of progression from subcritical to critical disease is consistent with observations in patients who have had prior negative cardiac catheterizations.