Comparing downstream consequences of normal exercise stress echocardiograms and cardiac computed tomography angiography scans in patients suspected of having of obstructive coronary artery disease: a retrospective cohort study of Tricare beneficiaries.

To compare overall number of downstream tests and total costs between negative exercise stress echocardiograms (ESE) or cardiac computed tomography angiography scans (CCTA) in symptomatic Tricare beneficiaries suspected of having coronary artery disease (CAD). This is a retrospective cohort study examining 651 propensity-matched patients who underwent ESE or CCTA with normal results between 2008 and 2014 at the United States' largest Department of Defense hospital. The total number of additional downstream tests over the next five years was determined. The total costs associated with each arm, inclusive of the initial test and all subsequent tests, were calculated using the 2018 Medicare Physician Fee Schedule. 18.5 percent of patients with a normal ESE result underwent some additional form of cardiac testing over the five years after initial testing compared to 12.8 percent of patients with a normal CCTA. The absolute difference in total number of downstream tests between both study groups was 5.7 percent (p = 0.03). When factoring the costs of the initial test as well as the downstream tests, the ESE group was associated with overall lower costs compared to the CCTA group, 351 United States Dollars (USD) versus 496 USD (p < 0.0001). This study demonstrates that, when compared to CCTA, ESE is associated with a higher total number of downstream tests, but overall lower total costs when chosen as initial testing strategy for suspected CAD.

2020 SCCT Guideline for Training Cardiology and Radiology Trainees as Independent Practitioners (Level II) and Advanced Practitioners (Level III) in Cardiovascular Computed Tomography: A Statement from the Society of Cardiovascular Computed Tomography.

Cardiovascular computed tomography (CCT) is a well-validated noninvasive imaging tool with an ever-expanding array of applications beyond the assessment of coronary artery disease. These include the evaluation of structural heart diseases, congenital heart diseases, peri-procedural electrophysiology applications, and the functional evaluation of ischemia. This breadth requires a robust and diverse training curriculum to ensure graduates of CCT training programs meet minimum competency standards for independent CCT interpretation. This statement from the Society of Cardiovascular Computed Tomography aims to supplement existing societal training guidelines by providing a curriculum and competency framework to inform the development of a comprehensive, integrated training experience for cardiology and radiology trainees in CCT. This article is being published synchronously in Radiology: Cardiothoracic Imaging, Journal of Cardiovascular Computed Tomography, and JACC: Cardiovascular Imaging. © 2020 Society of Cardiovascular Computed Tomography. Published by RSNA with permission.

2020 SCCT Guideline for Training Cardiology and Radiology Trainees as Independent Practitioners (Level II) and Advanced Practitioners (Level III) in Cardiovascular Computed Tomography: A Statement from the Society of Cardiovascular Computed Tomography.

Cardiovascular computed tomography (CCT) is a well-validated non-invasive imaging tool with an ever-expanding array of applications beyond the assessment of coronary artery disease. These include the evaluation of structural heart diseases, congenital heart diseases, peri-procedural electrophysiology applications, and the functional evaluation of ischemia. This breadth requires a robust and diverse training curriculum to ensure graduates of CCT training programs meet minimum competency standards for independent CCT interpretation. This statement from the Society of Cardiovascular Computed Tomography aims to supplement existing societal training guidelines by providing a curriculum and competency framework to inform the development of a comprehensive, integrated training experience for cardiology and radiology trainees in CCT.

2020 SCCT Guideline for Training Cardiology and Radiology Trainees as Independent Practitioners (Level II) and Advanced Practitioners (Level III) in Cardiovascular Computed Tomography: A Statement from the Society of Cardiovascular Computed Tomography.

Cardiovascular computed tomography (CCT) is a well-validated non-invasive imaging tool with an ever-expanding array of applications beyond the assessment of coronary artery disease. These include the evaluation of structural heart diseases, congenital heart diseases, peri-procedural electrophysiology applications, and the functional evaluation of ischemia. This breadth requires a robust and diverse training curriculum to ensure graduates of CCT training programs meet minimum competency standards for independent CCT interpretation. This statement from the Society of Cardiovascular Computed Tomography aims to supplement existing societal training guidelines by providing a curriculum and competency framework to inform the development of a comprehensive, integrated training experience for cardiology and radiology trainees in CCT.

Assessment of Semi-automated Computed Tomographic Measures of Segmental Perfusion Defects in a Swine Model (Sus scrofa) of Intermediate Coronary Lesions.

Computed tomographic myocardial perfusion (CTP) imaging is a tool that shows promise in emergent settings for defining the hemodynamic significance of coronary artery disease. In this study, we examined the accuracy with which the transmural perfusion ratio (TPR) derived through semiautomated CTP analysis reflected segmental perfusion defects associated with intermediate coronary artery lesions in swine. Lesions (diameter stenosis, 65% ± 11%) of the left anterior descending coronary artery (LAD) were created in 10 anesthetized female swine (weight, 47.5 ± 1.9 kg) by using a pneumatic occlusion device implanted on the LAD. Occluder inflation pressures were adjusted to maintain fractional flow reserve (FFR, 74.3 ± 1.7) during adenosine infusion (140ug/kg/min). Static CTP imaging using a stress-rest protocol and segmental TPR derived from semiautomated CT perfusion software was compared with microsphere-derived TPR (mTPR) by using a 16-segment model and polar mapping. Intermediate LAD stenosis was verified through multiplanar coronary CT angiography. Receiver operating characteristic analysis identified an optimal threshold for segmental perfusion defects for intermediate lesions (TPR threshold, ≤0.80); however, the area under the receiver operating characteristic curve was 0.58, and the overall accuracy was 63%. At this threshold, the sensitivity and specificity were 65% and 61%, and the positive and negative predictive values were 61% and 65%, respectively. Although CTP-TPR illustrated segmental perfusion defects with intermediate lesions, the disparity between CTP-TPR and mTPR measures of segmental perfusion suggests that further advances in analysis software may be necessary to improve the localization of segmental defects for intermediated lesions.

Adoption of coronary artery disease - Reporting and Data System (CAD-RADS™) and observed impact on medical therapy and systolic blood pressure control.

BACKGROUND: CAD-RADS was developed to standardize communication of per-patient maximal stenosis on coronary CT angiography (CCTA) and provide treatment recommendations and may impact primary prevention care and resource utilization. The authors sought to evaluate CAD-RADS adoption on preventive medical therapy and risk factor control amongst a mixed provider population. METHODS: Statins, aspirin (ASA), systolic blood pressure and, when available, lipid panel changes were abstracted for 1796 total patients undergoing CCTA in the 12 months before (non-standard reporting, NSR, cohort) and after adoption of the CAD-RADS reporting template. Only initiation of a medication in a treatment naïve patient, escalation from baseline dose, or transition to a higher potency was considered an escalation/initiation in lipid therapy. RESULTS: The CAD-RADS reporting template was utilized in 83.7% (751/897) of CCTAs after the CAD-RADS adoption period. After adjusting for any coronary artery disease (CAD) on CCTA, statin initiation/escalation was more commonly observed in the CAD-RADS cohort (aOR 1.46; 95%CI 1.12-1.90, p = 0.005), driven by higher rates of new statin initiation (aOR 1.79; 95%CI 1.23-2.58, p = 0.002). This resulted in a higher observed rates of total cholesterol improvement in the CAD-RADS cohort (58% vs 49%, p = 0.016). New ASA initiation was similar between reporting templates after adjustment for CAD on CCTA (aOR 1.40; 95%CI 0.97-2.02, p = 0.069). The ordering provider's specialty (cardiology vs non-cardiology) did not significantly impact the observed differences in initiation/escalation of statins and ASA (pinteraction = NS). CONCLUSIONS: Adoption of CAD-RADS reporting was associated with increased utilization of preventive medications, regardless of ordering provider specialty.

Myocardial Assessment with Cardiac CT: Ischemic Heart Disease and Beyond.

PURPOSE OF REVIEW: The aim of this review is to highlight recent advancements, current trends, and the expanding role for cardiac CT (CCT) in the evaluation of ischemic heart disease, nonischemic cardiomyopathies, and some specific congenital myocardial disease states. RECENT FINDINGS: CCT is a highly versatile imaging modality for the assessment of numerous cardiovascular disease states. Coronary CT angiography (CCTA) is now a well-established first-line imaging modality for the exclusion of significant coronary artery disease (CAD); however, CCTA has modest positive predictive value and specificity for diagnosing obstructive CAD in addition to limited capability to evaluate myocardial tissue characteristics. SUMMARY: CTP, when combined with CCTA, presents the potential for full functional and anatomic assessment with a single modality. CCT is a useful adjunct in select patients to both TTE and CMR in the evaluation of ventricular volumes and systolic function. Newer applications, such as dynamic CTP and DECT, are promising diagnostic tools offering the possibility of more quantitative assessment of ischemia. The superior spatial resolution and volumetric acquisition of CCT has an important role in the diagnosis of other nonischemic causes of cardiomyopathies.

Effects of adenosine and regadenoson on hemodynamics measured using cardiovascular magnetic resonance imaging.

BACKGROUND: Adenosine or regadenoson vasodilator stress cardiovascular magnetic resonance (CMR) is an effective non-invasive strategy for evaluating symptomatic coronary artery disease. Vasodilator injection typically precedes ventricular functional sequences to efficiently reduce overall scanning times, though the effects of vasodilators on CMR-derived ventricular volumes and function are unknown. METHODS: We prospectively enrolled 25 healthy subjects to undergo consecutive adenosine and regadenoson administration. Short axis CINE datasets were obtained on a 1.5 T scanner following adenosine (140mcg/kg/min IV for 6 min) and regadenoson (0.4 mg IV over 10 s) at baseline, immediately following administration, at 5 min intervals up to 15 min. Hemodynamic response, bi-ventricular volumes and ejection fractions were determined at each time point. RESULTS: Peak heart rate was observed early following administration of both adenosine and regadenoson. Heart rate returned to baseline by 10 min post-adenosine while remaining elevated at 15 min post-regadenoson (p = 0.0015). Left ventricular (LV) ejection fraction (LVEF) increased immediately following both vasodilators (p < 0.0001 for both) and returned to baseline following adenosine by 10 min (p = 0.8397). Conversely, LVEF following regadenoson remained increased at 10 min (p = 0.003) and 15 min (p = 0.0015) with a mean LVEF increase at 15 min of 4.2 ± 1.3%. Regadenoson resulted in a similar magnitude reduction in both LV end-diastolic volume index (LVEDVi) and LV end-systolic volume index (LVESVi) at 15 min whereas LVESVi resolved at 15 min following adenosine and LVEDVi remained below baseline values (p = 0.52). CONCLUSIONS: Regadenoson and adenosine have significant and prolonged impact on ventricular volumes and LVEF. In patients undergoing vasodilator stress CMR where ventricular volumes and LVEF are critical components to patient care, ventricular functional sequences should be performed prior to vasodilator use or consider the use of aminophylline in the setting of regadenoson. Additionally, heart rate resolution itself is not an effective surrogate for return of ventricular volumes and LVEF to baseline.

Left atrial appendage morphology and risk of stroke following pulmonary vein isolation for drug-refractory atrial fibrillation in low CHA2DS2Vasc risk patients.

BACKGROUND: Cardiac CT angiography (CCTA) has become an important adjunct in the structural assessment of the pulmonary veins (PV) prior to pulmonary vein isolation (PVI). Published data is conflicting regarding a relationship between left atrial appendage (LAA) and the risk of ischemic stroke (CVA) following PVI. We investigated the associations of volumetric and morphologic left atrial (LA) and LAA measurements for CVA following PVI. METHODS: We retrospectively reviewed 332 consecutive patients with drug refractory atrial fibrillation who obtained cardiac CT angiogram (CCTA) prior to PVI. Baseline demographic data, procedural and lab details, and outcomes were obtained from abstraction of an electronic medical records system. LA, LAA, and PV volumes were measured using CCTA datasets utilizing a semi-automated 3D workstation application. LAA morphology was assigned utilizing volume rendered images as previously described. RESULTS: The study cohort was 55 ± 13 years-old, 83.7% male, low CVA risk (median CHA2DS2Vasc 1; IQR 1, 3), and 30.4% were treated with novel oral anticoagulants. Chicken wing (CW) was the most common morphology (52%), followed by windsock (WS), cauliflower (CF), and cactus (CS) at 18, 9, and 2%, respectively. CVAs occurred in 4 patients following PVI with median time to CVA of 170.5 days. All CVAs were observed in CW morphology patients. When comparing CW morphology with non-CW morphology, CVAs occurred more frequently with the CW morphology (2.1% vs 0%, p = 0.03). This difference was not significant, though, after adjusting for CHA2DS2Vasc risk factors (p = 0.14). CONCLUSION: The CW morphology was observed more commonly in patients who experienced post-PVI CVA. After adjusting for CHA2DS2Vasc risk factors, CW morphology was not an independent predictor of post-PVI CVA. These findings should be interpreted in the setting of a low CVA event rate amongst a low risk population that was highly compliant with indicated anticoagulation therapy.

Association of tobacco use and cessation with coronary atherosclerosis.

BACKGROUND AND AIMS: The impact of tobacco use and cessation on atherogenesis remains unclear. We aimed to study the association of tobacco use and prior cessation with the presence, extent and severity of atherosclerosis on coronary computed tomographic angiography (CTA). METHODS: We examined 1798 consecutive symptomatic patients without known coronary artery disease (CAD) referred for CTA, stratified by smoking status (never, current [within 30 days], or former [>30 days before CTA]). Plaque severity (none, <50%, ≥50% stenosis), composition (non-calcified [NCP], partially calcified [PCP], or calcified plaque [CP]), and segment involvement score (SIS) were visually graded. Multivariate analysis was performed, adjusting for CAD risk factors and cholesterol lowering medication use. RESULTS: The median age of patients was 50 years [IQR:42-58] (61% male), with 74% never smokers, 12% current smokers, and 14% former smokers (median quit duration = 12 years [IQR:3-26]). Smoking exposure in former versus current smokers was 11 [IQR:5-25] and 10 [IQR:2-20] pack-years, respectively (p = 0.01). Compared to never smokers, current smokers demonstrated an increased odds ratio of all plaque types (adjusted OR: any NCP = 1.55 [95% CI 1.04-2.32], p = 0.03; any PCP = 1.61 [1.10-2.37], p = 0.02; any CP = 1.93 [1.32-2.81], p = 0.001), non-obstructive CAD (aOR = 1.47 [1.04, 2.07], p = 0.03), obstructive CAD (aOR = 1.81 [1.01-3.24], p = 0.047), and SIS > 4 (aOR = 1.60 [1.04-2.46], p = 0.03). Compared to current smoking, prior smoking cessation (≥12 years) was associated with a decreased odds ratio of any NCP (aOR = 0.42 [0.19-0.90], p = 0.03), CP (aOR = 0.43 [0.22-0.84], p = 0.02), and obstructive CAD (aOR = 0.40, [0.15-0.98], p = 0.048). CONCLUSIONS: Current smoking is independently associated with the presence and extent of coronary plaque, and a higher risk of non-obstructive and obstructive CAD compared to never smoking. Prior smoking cessation correlated with improvements in CTA-identified plaque measures.

PROMISE of Coronary CT Angiography: Precise and Accurate Diagnosis and Prognosis in Coronary Artery Disease.

Coronary computed tomography angiography (CCTA) is a rapidly growing and powerful diagnostic test that offers a great deal of precision with respect to diagnosing coronary artery disease (CAD). Guideline statements for patients with stable ischemic heart disease have recommended CCTA for only a limited portion of intermediate-risk patients who have relative or absolute contraindications for exercise or vasodilator stress testing. The publication of two large, prospective randomized clinical trials, the Prospective Multicenter Imaging Study for Evaluation of Chest Pain and the Scottish Computed Tomography of the Heart Trial are likely to expand these indications. These new data from large trials, in addition to other studies, show that CCTA is highly sensitive for the detection of CAD, identifies high-risk patients for cardiac events based on extent or plaque morphology of CAD that would not be identified by other noninvasive means, and provides significantly greater diagnostic certainty for proper treatment, including referral for invasive coronary angiography with revascularization more appropriately. Superior diagnostic accuracy and prognostic data with CCTA, when compared with other functional stress tests, may result in a reduction in unnecessary downstream testing and cost savings. In addition, newer CCTA applications hold the promise of providing a complete evaluation of a patient's coronary anatomy as well as a per-vessel ischemic evaluation. This review focuses on the interval knowledge obtained from newer data on CCTA in patients with stable ischemic heart disease, primarily focusing on the contributions of the Prospective Multicenter Imaging Study for Evaluation of Chest Pain and the Scottish Computed Tomography of the Heart Trial.

Rest-Only Myocardial CT Perfusion in Acute Chest Pain.

OBJECTIVES: Cardiac computed tomography perfusion (CTP) using stress testing is an emerging application in the field of cardiac computed tomography. We evaluated patients with acute chest pain (CP) in the emergency department (ED) with evidence of obstructive coronary artery disease (CAD), defined as >70% stenosis on coronary computed tomography angiography (CCTA) and confirmed by invasive coronary angiography (ICA), to evaluate the applicability of resting CTP in the acute CP setting. METHODS: From January to December 2013, 183 low-intermediate risk symptomatic patients with negative cardiac biomarkers and no known CAD underwent a rapid CCTA protocol in the ED. Of these, 4 patients (1.4%) had obstructive CAD (≥70% stenosis) on CCTA confirmed by ICA. All 183 CCTA studies were evaluated retrospectively with CTP software by a transmural perfusion ratio (TPR) method with a superimposed 17-segment model. A TPR value <0.99 was considered abnormal based on previously published data. RESULTS: A total of four patients were included in this pilot analysis. The duration from resolution of CP to performance of CCTA ranged from 1.6 to 5.0 hours. Three patients underwent revascularization, two with percutaneous coronary intervention (PCI) and one with coronary artery bypass grafting. The fourth patient was managed with aggressive medical therapy. Two patients had multivessel obstructive CAD and two patients had single-vessel CAD. The first patient underwent CCTA 5 hours after resolution of CP symptoms. CCTA demonstrated noncalcified obstructive CAD in the mid-LAD and mid-right coronary artery. ICA showed good correlation by quantitative coronary assessment (QCA) in both vessels and the patient underwent PCI. CTP analysis demonstrated perfusion defects in the LAD and right coronary artery territories. The second patient underwent CCTA 1.6 hours after resolution of CP symptoms with findings of obstructive ostial left main CAD. ICA confirmed obstructive left main CAD by QCA and intravascular ultrasound. The patient underwent revascularization with coronary artery bypass grafting. CTP demonstrated perfusion defects in the anterior and lateral wall segments. The third patient was evaluated for CP in the ED with CCTA demonstrating single-vessel CAD 10 hours after resolution of symptoms with findings of a noncalcified obstructive stenosis in the mid-LAD. The patient subsequently underwent ICA demonstrating good correlation to the CCTA findings in the LAD by QCA. CTP analysis revealed perfusion defects in LAD territory. He was successful treated with PCI. The final patient underwent CCTA 5.4 hours following resolution of CP with the finding of an intermediate partially calcified stenosis in the distal LAD. ICA was performed, with fractional flow reserve demonstrating a hemodynamically insignificant distal LAD at 0.86. CTP detected a perfusion defect in the LAD territory. CONCLUSIONS: When positive, rest CTP may have value in the risk stratification of patients presenting to the ED with nontraumatic acute CP.

Use of carbonated water in reduction of adjacent gastric activity in 456 consecutive technetium-99m myocardial perfusion imaging studies.

BACKGROUND: Small, observational trials have suggested a reduction in adjacent gastric activity with ingestion of soda water in myocardial perfusion imaging (MPI). We report our findings prior to and after implementation of soda water in 467 consecutive MPI studies. METHODS: Consecutive MPI studies performed at a high-volume facility referred for vasodilator (VD) or exercise treadmill testing (ETT) were retrospectively reviewed before and after implementation of the soda water protocol. Patients undergoing the soda water protocol received 100 ml of soda water administered 30 min prior to image acquisition and after stress. Studies were performed using a same day rest/stress protocol. Incidence of adjacent gastric activity, diaphragmatic attenuation, stress and rest perfusion defects, and major adverse cardiovascular events (MACE) outcomes defined as death, myocardial infarction, stroke, reevaluation for chest pain, and late revascularization (>90 days from MPI) were abstracted using International Classification of Diseases, Ninth Revision (ICD-9) search. RESULTS: Two hundred and eighteen studies were performed prior to implementation of the soda water protocol and 249 studies were performed with the use of soda water. Baseline demographic data were equal between the groups with the exception of more patients undergoing VD stress receiving soda water (p < 0.001). Soda water was not associated with a decreased incidence of adjacent gastric activity with stress (54.7% versus 61.9% with no soda water, p = 0.129) or rest (68.6% versus 69.5% with no soda water, p = 0.919) imaging. Less adjacent gastric activity was observed with patients undergoing ETT who received soda water (42.5% versus 56.9% with no soda water, p = 0.031), but no difference was observed between the groups with VD stress (69.0% versus 68.1% with no soda water, p = 1.000). CONCLUSION: The use of soda water prior to technetium-99m MPI was associated with lower rates of adjacent gastric activity only in patients undergoing ETT stress but not rest or VD stress. This differs from previously published data.

The lack of obstructive coronary artery disease on coronary CT angiography safely reduces downstream cost and resource utilization during subsequent chest pain presentations.

OBJECTIVE: The purpose of this study is to investigate the cost and resource use due to chest pain (CP) evaluations after initial coronary CT angiography (CCTA) stratified by coronary artery disease (CAD) burden. METHODS: We examined 1518 patients referred for CCTA from January 2005 to July 2012 for downstream evaluation after CCTA during a median follow-up of 351 days. Results were stratified by CAD burden as quantified on CCTA into no CAD, nonobstructive CAD (<50% stenosis), or obstructive CAD (≥50% stenosis). The incidence of ischemic testing at the time of recurrent evaluation (defined as a composite of clinic visit, emergency department encounter, or ischemic testing after the index CCTA for CP, atypical CP, or angina defined by ICD-9 code), the testing modality used, and frequency of testing were abstracted and used to calculate the direct costs of downstream utilization. Major adverse cardiovascular events defined as all-cause mortality, nonfatal myocardial infarction, stroke, or revascularization >90 days from CCTA were abstracted using ICD-9 codes and Social Security Death Index query. RESULTS: A total of 174 patients (11.5%) underwent evaluation for CP after index CCTA with a higher rate of subsequent clinical visits among obstructive CAD patients compared to those with nonobstructive CAD and no CAD (17.8% vs 13.9% vs. 7.5%; P < .001). A significant reduction in the incidence of repeat ischemic testing was observed in patients with no CAD and nonobstructive CAD (P = .002). This resulted in a lower per-patient cost in the nonobstructive CAD and no CAD patients (median [interquartile range 25-75]: $2952 [$307-2952] and $235 [$0-2880]) when compared with patients with obstructive CAD (median [interquartile range 25-75]: $5832 [$5498-17,459]; P < .001). Major adverse cardiovascular events were not different in the 90 patients that underwent repeat testing at the time of CP evaluation when compared with the 84 patients for whom testing was deferred. CONCLUSION: Absence of CAD on initial CCTA was associated with lower costs and decreased downstream utilization compared to the presence of nonobstructive and obstructive CAD on CCTA during median follow-up of 351 days.

Management of Coronary Artery Calcium and Coronary CTA Findings.

Coronary artery calcium (CAC) testing and coronary computed tomography angiography (CTA) have significant data supporting their ability to identify coronary artery disease (CAD) and classify patient risk for atherosclerotic cardiovascular disease (ASCVD). Evidence regarding CAC use for screening has established an excellent prognosis in patients with no detectable CAC, and the ability to risk re-classify the majority of asymptomatic patients considered intermediate risk by traditional risk scores. While data regarding the ideal management of CAC findings are limited, evidence supports statin consideration in patients with CAC > 0 and individualized aspirin therapy accounting for CAD risk factors, CAC severity, and factors which increase a patient's risk of bleeding. In patients with stable or acute symptoms undergoing coronary CTA, a normal CTA predicts excellent prognosis, allowing reassurance and disposition without further testing. When CTA identifies nonobstructive CAD (<50 % stenosis), observational data support consideration of statin use/intensification in patients with extensive plaque (at least four coronary segments involved) and patients with high-risk plaque features. In patients with both nonobstructive and obstructive CAD, multiple studies have now demonstrated an ability of CTA to guide management and improve CAD risk factor control. Still, significant under-treatment of cardiovascular risk factors and high-risk image findings remain, among concerns that CTA may increase invasive angiography and revascularization. To fully realize the impact of atherosclerosis imaging for ASCVD prevention, patient engagement in lifestyle changes and the modification of ASCVD risk factors remain the foundation of care. This review provides an overview of available data and recommendations in the management of CAC and CTA findings.

Safe and rapid disposition of low-to-intermediate risk patients presenting to the emergency department with chest pain: a 1-year high-volume single-center experience.

BACKGROUND: Coronary CT angiography (CTA) is a powerful tool for the evaluation of chest pain in the emergency department (ED). Some debate persists regarding its cost-effectiveness in a low-to-intermediate risk population. OBJECTIVE: This study sought to evaluate the safety and cost-effectiveness of coronary CTA for low-to-intermediate risk patients presenting to the ED with chest pain in a closed-loop referral system. METHODS: Chest pain patients were evaluated in the ED via a local rapid coronary CTA protocol and tracked prospectively for ED throughput, disposition, chest pain recidivism, and cost utilization as compared with an age-matched cohort evaluated for chest pain treated with usual care. RESULTS: One hundred eighty-three patients underwent the rapid coronary CTA protocol compared with an age-matched cohort of 184 patients treated with usual care. The median follow-up period for major adverse cardiovascular events in the coronary CTA group was 9.0 months (range, 1.8-14.5 months) and 11.1 months (range, 0-14.0 months) for the age-matched cohort. The median ED length of stay (LOS) was 5.8 hours (range, 2.6-12.3 hours) for the rapid coronary CTA cohort and 12.2 hours (range, 1.7-40.3 hours) for the age-matched cohort (P < .001). The median time to performance of coronary CTA was 2.5 hours (range, 0.4-8.7 hours) with a median time from coronary CTA performance to disposition of 2.9 hours (range, 0.8-8.6 hours). Total median hospital LOS was 5.9 hours (range, 2.7-124 hours) in the rapid coronary CTA cohort compared with 25.0 hours (range, 1.2-208 hours) in the age-matched cohort (P < .001). Hospital admission was more common in the age-matched cohort (98.9% vs 9.3%; P < .001). There was a significant reduction in total payer cost in coronary CTA group when compared to usual care ($182,064.55 vs $685,190.77; P < .001). CONCLUSIONS: Coronary CTA for ED risk stratification and disposition within a closed referral system resulted in the shortest ED LOS published to date while being safe and cost-effective.

A review of anomalous origination of a coronary artery from an opposite sinus of Valsalva (ACAOS) impact on major adverse cardiovascular events based on coronary computerized tomography angiography: a 6-year single center review.

BACKGROUND: Anomalous origination of a coronary artery from an opposite sinus of Valsalva (ACAOS) is a rare finding that is typically found on autopsy in a person with sudden cardiac death or during routine cardiovascular testing. The true prevalence is unknown for this reason. There is also question to the specific anatomy of the anomalies themselves and how best to correct them. METHODS: We performed a retrospective chart review of all coronary computed tomography angiography (CCTA) studies to evaluate the incidence of all-cause mortality, nonfatal myocardial infarction, stroke and late revascularization (>90 days following CCTA) from January 2005 until July 2012. We describe the origin of the artery, its course, slit-like appearance and treatment in this population. RESULTS: We reviewed 1518 CCTA reports and identified 22 patients with ACAOS with an incidence of 1.4% of our original study population over a review period of 6 years with a resultant median follow-up period of 25 months [interquartile range (IQR)25,75 12-34 months]. The indication for CCTA was for chest pain in the majority of patients (73%). We had one patient undergo surgical repair and one with coronary bypass grafting for unrelated symptomatic coronary artery disease. CONCLUSION: ACAOS continues to be a rare but presumed fatal condition in subsets identified to carry high risk features. As the characteristics of the anomalous vessels that increase risk are still debated, over an intermediate to long follow up in a single large center, none of the different anomalous findings with varying degrees of high risk findings were associated with sudden death.