Detection of non-ST-elevation myocardial infarction and unstable angina in the acute setting: meta-analysis of diagnostic performance of multi-detector computed tomographic angiography

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Abstract

Multi-detector computed tomography angiography (MDCTA) has been increasingly used in the evaluation of the coronary arteries. The purpose of this study was to review the literature on the diagnostic performance of MDCTA in the acute setting, for the detection of non-ST-elevation myocardial infarction (NSTEMI) and unstable angina pectoris (UAP).

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Methods
A Pubmed and manual search of the literature published between January 2000 and June 2007 was performed. Studies were included that compared MDCTA with clinical outcome and/or CA in patients with acute chest pain, presenting at the emergency department. More specifically, studies that only included patients with initially negative cardiac enzymes suspected of having NSTEMI or UAP were included. Summary estimates of diagnostic odds ratio (DOR), sensitivity and specificity, negative (NLR) and positive likelihood ratio (PLR) were calculated on a patient basis. Random-effects models and summary receiver operating curve (SROC) analysis were used to assess the diagnostic performance of MDCTA with 4 detectors or more. The proportion of non assessable scans (NAP) on MDCTA was also evaluated. In addition, the influence of study characteristics of each study on diagnostic performance and NAP was investigated with multivariable logistic regression.

Results
Nine studies totalling 566 patients, were included in the meta-analysis: one randomised trial and eight prospective cohort studies. Five studies on 64-detector MDCTA and 4 studies on MDCTA with less than 64 detectors were included (32 detectors n = 1, 16 detectors n = 2, 16 and 4 detectors n = 1). Pooled DOR was 131.81 (95%CI, 50.90├óÔé¼ÔÇ£341.31). The pooled sensitivity and specificity were 0.95 (95%CI, 0.90├óÔé¼ÔÇ£0.98) and 0.90 (95%CI, 0.87├óÔé¼ÔÇ£0.93). The pooled NLR and PLR were 0.12 (95%CI, 0.06├óÔé¼ÔÇ£0.21) and 8,60 (95%CI, 5.03├óÔé¼ÔÇ£14,69).

The results of the logistic regressions showed that none of the investigated variables had influence on the diagnostic performance or NAP

Conclusion
MDCTA of the coronary arteries performs good to excellent in the diagnosis of coronary artery disease in the acute setting and it can be used for early exclusion of NSTEMI or UAP in patients in the emergency department.

Background
Acute chest pain accounts for approximately 6.5% of all emergency department visits in the US 1,2. Failure to diagnose myocardial ischemia as a cause of acute chest pain has serious implications and the triage of patients with possible ischemia is often difficult. To reduce diagnostic error, many patients that present at the emergency department are admitted for observation, even when no initial ECG changes or elevated cardiac enzymes are present. Emergency departments have therefore developed chest pain units and diagnostic protocols commonly including serial cardiac enzyme evaluations and ECG's, supplemented with some form of stress testing with or without imaging 3. Many of these patients are found to have no acute coronary syndrome (ACS) and more than 2 million patients with acute chest pain are admitted to the hospital without developing an ACS 4,5. Data from Germany reveal that the number of potentially unnecessary hospital days is high, amounting to as much as 839 per 100 patients admitted for acute chest pain 6.

Non invasive access to coronary anatomy has become available with the emergence of multi-detector computed tomography (MDCTA) of the coronary arteries. Diagnostic performance of MDCTA has been evaluated in many studies 7. Even though appropriate indications for MDCTA remain largely work in progress, the technique has been used as a tool to rule out ACS in the emergency department. 8-16/>/>/>/>/>/>/>/>/>/>/>/>/>/>

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