Vai trò mới nổi của MSCT cho người bệnh đau thắt ngực cấp

The BEACON Better Evaluation of Acute Chest Pain with Computed Tomography Angiography, n= 500 pts... MEDIC Coronary CT Angiography for Suspected ACS The BEACON Better Evaluation of Acut

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Emerging Roles of MSCT for Patient with

Acute Chest Pain

Bs CK II Nguyễn Xuân Trình

Bs Phan Thanh Hải

Department of Cardiology MEDIC Medical Center

MEDIC

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Acute Chest Pain(ACP) And the ED

2015 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation

• Several cardiac and non-cardiac conditions may mimic NSTE-ACS

• Differential diagnosis of NSTE-ACS:

• Aortic dissection,

• Pulmonary embolism

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MEDIC

Acute Coronary Syndrome and the ED

• 8-10 million ED chest pain presentations/ yr in US

• 85-95% have a final diagnosis other than MI or UA

• Unnecessary admissions (60-80%) and testing to exclude ACS

• But, big downside for missed diagnosis (up to 5%)

• General agreement in USA, <1% miss rate is needed

• Clinical exam, risk factors, and markers can’t do it

Harold Litt Available online at www.nasci.org

Udo Hoffmann Circ Cardiovasc Imaging 2009;2:251-263

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MEDIC

Goals for ED ACP Evaluation

• Exclude or diagnose causes with morbidity if untreated

• Discharge safely if negative - Sens, NPV

Goal is <1% 30-day event rate

• Provide good “warranty period” for negative evaluation

• Provide risk assessment for outpatient treatment

• Do it efficiently and as cheaply as possible

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MEDIC

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Coro CTA in Acute Chest Pain and ED

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MEDIC

Cardiac MSCT as the Solution

• Single center trials (some large):

- CT is safe (<1% 30-day event rate )

- CT is efficient (8-12 hrs vs 24 hrs usual care)

- CT costs less ($250 - $2500 savings per pt)

- CT reduces repeat ED visits and readmissions

• Multicenter trials:

– CT-STAT – ACRIN PA 4005 and ROMICAT II – Why does CT work? It acts as a surrogate for cath

– ED physicians and patients believe the results

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(American College of Radiology Imaging Network / Pennsylvania Department of Health)

Multicenter randomized, controlled Trial

N=1,370 patients

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MEDIC

(n=501)

Standard Evaluation

(n=499)

P- Value

Missed ACS /72h 0% 0%

28-day MACE (Safety) 0.4% 1.0% 0.37

ED Costs of care 2053 2532 < 0.0001

ROMICAT II

Udo Hoffmann et al N Engl J Med 2012 Jul 26; 367(4): 299–308

• N = 1000 pts low-intermediate risk patients

• CCTA (n=501) vs Standard Evaluation(n= 499)

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MEDIC

J Am Coll Cardiol 2016;67(1):16-26

The BEACON (Better Evaluation of Acute Chest Pain with Computed Tomography Angiography), n= 500 pts

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MEDIC

Coronary CT Angiography for Suspected ACS

J Am Coll Cardiol 2016;67(1):16-26

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MEDIC

Coronary CT Angiography for Suspected ACS

J Am Coll Cardiol 2016;67(1):16-26

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MEDIC

Smulders et al Am Heart J July 2016; Vol 177:102-11

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MEDIC

Smulders et al Am Heart J July 2016; Vol 177:102-11

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MEDIC

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Rybicki et al Appropriate Utilization of Cardiovascular Imaging in Emergency Department Patients With Chest Pain J Am Coll Radiol 2016;13:e1-e29

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MEDIC

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MEDIC

Imaging of Patients for Whom the Initial Workup Is Diagnostic for STEMI or Noncardiac

Rybicki et al Appropriate Utilization of Cardiovascular Imaging in Emergency

Department Patients With Chest Pain J Am Coll Radiol 2016;13:e1-e29

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MEDIC

Suspected Non–ST-Segment Elevation ACS:

Early Assessment Pathway Based on Initial ECG, Biomarker Analysis, and Symptoms

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MEDIC

Suspected Non–ST-Segment Elevation ACS:

Observational Pathway—After Assessment of Serial Cardiac Troponin

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Suspected PE

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MEDIC Suspected AAS

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MEDIC

CONCLUSION: CCTA in the ACP

• CCTA has a high sensitivity (98-100%), Specificity 85% , NPV 100%

• Hs- Troponin is highly sensitive but less specific

• Appropriate indications of CCTA :

 CCTA as first test for low-intermediate risk pts with potential ACS

 Safety: 30-day MACE < 1%

 Efficiency

 Lower ED costs of care

 Equivocal initial diagnosis of NSTEMI/ACS

 Serial troponins or ECG not positive for NSTEMI/ACS

strategies for the management of patients with ACP

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MEDIC

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