Denmark: Coronary artery disease can be accurately ruled out in patients presenting with non-ST-segment elevation acute coronary syndrome (NSTEACS) with the use of coronary CT angiography (CTA), suggests findings from the VERDICT trial. This would spare some patients from subsequent testing and admission and would help to pinpoint the patients more likely to benefit from revascularization.
Findings of the study, published in the Journal of the American College of Cardiology, suggests that in patients with NSTEACS, coronary CTA can be conducted within 2 h of clinical diagnosis to quickly identify patients in whom invasive evaluation will be futile.
Current guidelines favor invasive angiography as the primary diagnostic test for patients with ACS, whereas coronary CTA is reserved for those with chest pain who have an intermediate pretest likelihood of CAD. However, up to one-third of these higher-risk patients sent for cath are found not to have obstructive disease, the authors from the current study point out.
Jesper J. Linde, Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark, and colleagues tested if coronary computed tomography angiography (CTA) may be used to exclude coronary artery stenosis ≥50% in patients with NSTEACS in the VERDICT (Very Early Versus Deferred Invasive Evaluation Using Computerized Tomography in Patients With Acute Coronary Syndromes).
The analysis included 1023 patients with confirmed NSTEACS. They were randomized in the ratio 1:1 to receive very early (within 12 h) (n=583) or standard (48 to 72 h) (n=440) invasive coronary angiography (ICA). A clinically blinded coronary CTA was conducted prior to ICA in both groups. All patients had a positive troponin or ischemic electrocardiographic changes at baseline, and 67% had at least one stenosis on invasive angiography.
The primary endpoint was the ability of coronary CTA to rule out coronary artery stenosis (≥50% stenosis) in the entire population, expressed as the negative predictive value (NPV), using ICA as the reference standard.
Key findings of the study include:
A coronary stenosis ≥50% was found by coronary CTA in 68.9% and by ICA in 67.4% of the patients.
Per-patient NPV of coronary CTA was 90.9% and the positive predictive value, sensitivity, and specificity were 87.9%, 96.5% and 72.4% respectively.
NPV was not influenced by patient characteristics or clinical risk profile and was similar in the very early and the standard strategy group.
"Coronary CTA has a high diagnostic accuracy to rule out clinically significant coronary artery disease in patients with NSTEACS," concluded the authors.
The study, "Coronary CT Angiography in Patients With Non-ST-Segment Elevation Acute Coronary Syndrome," is published in the Journal of the American College of Cardiology.
DOI: 10.1016/j.jacc.2019.12.012