Rule Out Myocardial Infarction by Computer Assisted Tomography - Full Text View

Purpose

The goal of this research is to determine noninvasively whether detection of coronary stenosis and plaque by multidetector computed tomography (MDCT) in patients with acute chest pain suspected of acute coronary syndrome (ACS) enhances triage, reduces cost and is cost effective. Among the 5.6 million patients with ACP presenting annually in emergency departments (ED) in the United States, a subgroup of two million patients is hospitalized despite normal initial cardiac biomarker tests and electrocardiogram (ECG). This subgroup is at low (20%) risk for ACS during the index hospitalization. Most (80-94%) patients with a diagnosis of ACS have a significant epicardial coronary artery stenosis ( >50% luminal narrowing). However, in -10% of patients non-stenotic coronary plaque triggers events, i.e. vasospasms, leading to myocardial ischemia. Since the absence of plaque excludes a coronary cause of chest pain, these patients could in theory be discharged earlier reducing unnecessary hospital admissions. Recent publications demonstrate high sensitivity and specificity of MDCT for the detection of significant coronary stenosis compared with coronary angiography and the detection of coronary plaque as validated with intravascular ultrasound. Using 64- slice MDCT we propose to study 400 patients with ACP, negative initial cardiac biomarkers and non-diagnostic ECG. We will analyze MDCT images for the presence of significant coronary artery stenosis and plaque and correlate the data with the clinical diagnosis of ACS (AHA guidelines) during the index hospitalization to determine the sensitivity and specificity. MDCT data, risk factors, and the results of standard diagnostic tests available at the time of MDCT will be used to generate a multivariate prediction function and derive a clinical decision rule. Based on this decision rule we will compare the diagnostic accuracies and cost effectiveness of competing strategies. We hypothesize that an MDCT- based diagnostic strategy will reduce the time to diagnosis of ACS, number of hospitalizations, and absolute cost of management of patients with acute chest pain compared to standard clinical care and is cost effective.

Condition	Intervention
Acute Coronary Syndrome Myocardial Infarction Unstable Angina Pectoris	Radiation: Cardiac Computed Tomography


Study Type:	Observational
Study Design:	Observational Model: Cohort Time Perspective: Prospective
Official Title:	Accuracy of Contrast Enhanced Multidetector Computed Tomography to Identify Cardiac Cause of Symptoms in Patients With Intermediate Likelihood of Acute Coronary Syndrome (ACS) - A Comparison to Standard Care

Resource links provided by NLM:

MedlinePlus related topics: CT Scans Chest Pain Heart Attack

U.S. FDA Resources

Further study details as provided by Massachusetts General Hospital:

Primary Outcome Measures:

Accuracy of CT derived features of coronary artery disease and LV function for ACS [ Time Frame: ED presentation to hospital discharge ] [ Designated as safety issue: Yes ]

Secondary Outcome Measures:

Major adverse cardiac events (MACE) - defined as death, myocardial infarction or coronary revascularization [ Time Frame: Follow up at 6 months and 2 year after index hospitalization ] [ Designated as safety issue: Yes ]

Biospecimen Retention: Samples With DNA

Plasma


Enrollment:	368
Study Start Date:	May 2005
Study Completion Date:	April 2009
Primary Completion Date:	May 2007 (Final data collection date for primary outcome measure)

Groups/Cohorts	Assigned Interventions
Acute Chest Pain Patients who presented to the emergency department with acute chest pain, with negative initial biomarkers and normal or non-ischemic ECG	Radiation: Cardiac Computed Tomography Localization of the heart position in a projectional topographic scan of the chest. Determination of contrast agent transit time: 10 ml contrast agent. CT coronary angiography: CT scan in spiral acquisition mode with 330 ms rotation time, 32 x 0.6 mm collimation, a pitch of 2.8 mm/rotation, tube voltage of 120 kVp, and maximum tube current of 850 mA. 80 ml of contrast agent, followed by 40 ml saline solution will be injected at a rate of 4 ml/s. The mean breath hold duration for this acquisition is approximately 13 seconds.

Groups/Cohorts

Assigned Interventions

Acute Chest Pain

Patients who presented to the emergency department with acute chest pain, with negative initial biomarkers and normal or non-ischemic ECG

Radiation: Cardiac Computed Tomography

Localization of the heart position in a projectional topographic scan of the chest.
Determination of contrast agent transit time: 10 ml contrast agent.
CT coronary angiography: CT scan in spiral acquisition mode with 330 ms rotation time, 32 x 0.6 mm collimation, a pitch of 2.8 mm/rotation, tube voltage of 120 kVp, and maximum tube current of 850 mA. 80 ml of contrast agent, followed by 40 ml saline solution will be injected at a rate of 4 ml/s. The mean breath hold duration for this acquisition is approximately 13 seconds.

Eligibility


Ages Eligible for Study:	18 Years and older (Adult, Senior)
Genders Eligible for Study:	Both
Accepts Healthy Volunteers:	No
Sampling Method:	Non-Probability Sample

Study Population

Patients who presented to the emergency department at Massachusetts General Hospital, with acute chest pain and with initial negative biomarkers and normal or non-ischemic ECG

Criteria

Inclusion Criteria:

Patients with any episode > five minutes of chest pain being admitted to rule out acute coronary syndrome

Exclusion Criteria:

Positive initial troponin or CK-MB tests
Diagnostic ECG changes (ST- segment elevation or horizontal ST- segment depression in more than two contiguous leads)
Unstable clinical condition (hemodynamically unstable, ventricular tachycardia, persistent chest pain despite adequate therapy)
Creatinine Clearance <50 mL/min
Known allergy to iodinated contrast agents
Patients on metformin therapy unable or unwilling to discontinue therapy for 48 hours after CT scan procedure
Known asthma, reactive airway disease
Patients currently in atrial fibrillation
Previous intolerance to beta blocker
Patients that are referred for coronary angiography/PCI by their PCP or cardiologist.

Contacts and Locations

Choosing to participate in a study is an important personal decision. Talk with your doctor and family members or friends about deciding to join a study. To learn more about this study, you or your doctor may contact the study research staff using the Contacts provided below. For general information, see Learn About Clinical Studies.

Please refer to this study by its ClinicalTrials.gov identifier: NCT00990262

Locations


United States, Massachusetts
Massachusetts General Hospital
Boston, Massachusetts, United States, 02114

Sponsors and Collaborators

Massachusetts General Hospital

Investigators


Principal Investigator:	Udo Hoffmann, MD, MPH	Massachusetts General Hospital

More Information

Publications:

Hoffmann U, Bamberg F, Chae CU, Nichols JH, Rogers IS, Seneviratne SK, Truong QA, Cury RC, Abbara S, Shapiro MD, Moloo J, Butler J, Ferencik M, Lee H, Jang IK, Parry BA, Brown DF, Udelson JE, Achenbach S, Brady TJ, Nagurney JT. Coronary computed tomography angiography for early triage of patients with acute chest pain: the ROMICAT (Rule Out Myocardial Infarction using Computer Assisted Tomography) trial. J Am Coll Cardiol. 2009 May 5;53(18):1642-50. doi: 10.1016/j.jacc.2009.01.052.

Mahabadi AA, Bamberg F, Toepker M, Schlett CL, Rogers IS, Nagurney JT, Brady TJ, Hoffmann U, Truong QA. Association of aortic valve calcification to the presence, extent, and composition of coronary artery plaque burden: from the Rule Out Myocardial Infarction using Computer Assisted Tomography (ROMICAT) trial. Am Heart J. 2009 Oct;158(4):562-8. doi: 10.1016/j.ahj.2009.07.027.

Truong QA, Toepker M, Mahabadi AA, Bamberg F, Rogers IS, Blankstein R, Brady TJ, Nagurney JT, Hoffmann U. Relation of left ventricular mass and concentric remodeling to extent of coronary artery disease by computed tomography in patients without left ventricular hypertrophy: ROMICAT study. J Hypertens. 2009 Dec;27(12):2472-82. doi: 10.1097/HJH.0b013e328331054a.

Hoffmann U, Nagurney JT, Moselewski F, Pena A, Ferencik M, Chae CU, Cury RC, Butler J, Abbara S, Brown DF, Manini A, Nichols JH, Achenbach S, Brady TJ. Coronary multidetector computed tomography in the assessment of patients with acute chest pain. Circulation. 2006 Nov 21;114(21):2251-60. Epub 2006 Oct 30. Erratum in: Circulation. 2006 Dec 19;114(25):e651.

Truong QA, Bamberg F, Mahabadi AA, Toepker M, Lee H, Rogers IS, Seneviratne SK, Schlett CL, Brady TJ, Nagurney JT, Hoffmann U. Left atrial volume and index by multi-detector computed tomography: comprehensive analysis from predictors of enlargement to predictive value for acute coronary syndrome (ROMICAT study). Int J Cardiol. 2011 Jan 21;146(2):171-6. doi: 10.1016/j.ijcard.2009.06.029. Epub 2009 Jul 16.

Manini AF, Dannemann N, Brown DF, Butler J, Bamberg F, Nagurney JT, Nichols JH, Hoffmann U; Rule-Out Myocardial Infarction using Coronary Artery Tomography (ROMICAT) Study Investigators. Limitations of risk score models in patients with acute chest pain. Am J Emerg Med. 2009 Jan;27(1):43-8. doi: 10.1016/j.ajem.2008.01.022.

Lehman SJ, Schlett CL, Bamberg F, Nieman K, Abbara S, Hoffmann U. Appearance of acute and chronic coronary occlusions in contrast-enhanced cardiac computed tomography. JACC Cardiovasc Imaging. 2008 Nov;1(6):809-11. doi: 10.1016/j.jcmg.2008.07.016. Epub 2008 Nov 18.

Publications automatically indexed to this study by ClinicalTrials.gov Identifier (NCT Number):

Pursnani A, Lee AM, Mayrhofer T, Ahmed W, Uthamalingam S, Ferencik M, Puchner SB, Bamberg F, Schlett CL, Udelson J, Hoffmann U, Ghoshhajra BB. Early resting myocardial computed tomography perfusion for the detection of acute coronary syndrome in patients with coronary artery disease. Circ Cardiovasc Imaging. 2015 Mar;8(3):e002404. doi: 10.1161/CIRCIMAGING.114.002404.

Hulten E, Goehler A, Bittencourt MS, Bamberg F, Schlett CL, Truong QA, Nichols J, Nasir K, Rogers IS, Gazelle SG, Nagurney JT, Hoffmann U, Blankstein R. Cost and resource utilization associated with use of computed tomography to evaluate chest pain in the emergency department: the Rule Out Myocardial Infarction using Computer Assisted Tomography (ROMICAT) study. Circ Cardiovasc Qual Outcomes. 2013 Sep 1;6(5):514-24. doi: 10.1161/CIRCOUTCOMES.113.000244. Epub 2013 Sep 10.

Seneviratne SK, Truong QA, Bamberg F, Rogers IS, Shapiro MD, Schlett CL, Chae CU, Cury R, Abbara S, Brady TJ, Nagurney JT, Hoffmann U. Incremental diagnostic value of regional left ventricular function over coronary assessment by cardiac computed tomography for the detection of acute coronary syndrome in patients with acute chest pain: from the ROMICAT trial. Circ Cardiovasc Imaging. 2010 Jul;3(4):375-83. doi: 10.1161/CIRCIMAGING.109.892638. Epub 2010 May 19.


Responsible Party:	Udo Hoffmann, MD MPH, Massachusetts General Hospital
ClinicalTrials.gov Identifier:	NCT00990262 History of Changes
Other Study ID Numbers:	2003P000458 R01HL080053-01
Study First Received:	September 30, 2009
Last Updated:	October 2, 2009
Health Authority:	United States: Institutional Review Board

Keywords provided by Massachusetts General Hospital:


acute chest pain emergency department cardiac computed tomography

Additional relevant MeSH terms:


Syndrome Infarction Myocardial Infarction Acute Coronary Syndrome Angina Pectoris Angina, Unstable Disease Pathologic Processes Ischemia Necrosis	Myocardial Ischemia Heart Diseases Cardiovascular Diseases Vascular Diseases Chest Pain Pain Neurologic Manifestations Nervous System Diseases Signs and Symptoms

ClinicalTrials.gov processed this record on September 29, 2016

Rule Out Myocardial Infarction by Computer Assisted Tomography (ROMICAT)